test fom 01 I consent to the storage of my data according to the Privacy Policy Register For Just4Keepers USAUpon Completion of this form you will be forwarded to the Payment Page!You MUST complete the payment for your registration to be complete.Upon receipt of payment, you will be forwarded a Confirmation emailContact Information Keeper First Name Last Name Date of Birth Gender MaleFemale High School Graduation Year Address Street Address Address Line 2 Cell Phone Home Phone City Country State / Province / Region Primary Email Address Secondary Email Find Out About Just4Keepers? Referred by a J4K Keeper (Please name them below)InternetFlyerOther (Please Specify Below) Which Club do you Currently Play For? If Other, Please Specify J4K Keeper who referred you? (If Applicable), Select the J4K USA Program You Are Registering For Jim Kloes-Central KansasNicki Swanson-central texasAdrian Clewlow-central virginiaErrin Stanton-CharlotteGreg Cope-delawareRick Zucchi-florida centralGiuseppe Weller-South FloridaGoalkeeper training hawaiiMark Phillips-idahoAntonio Torrico-marylandAlan Rubin-massachusetts westJim Kloes-melbourneRoy Howell & Phil Lucas-michiganAndy Woodcock-minnesotaJoshua Olsson - Stephen Wilson Swanger-montanaKevin-nashvilleDavid McCracken-North CaliforniaLuke Baxter-nebraskaRussell Dishman-West VirginiaDan Tunstall-Western TexasStephen Wilson Swanger-Washington StateLuis Cardoso-south texasJaime Bravo-south californiaJake Dodd-north west paSimon Robinson-pennsylvaniaBeni Brannigan-North TexasLarry Dolph-Northern VirginiaGavin Mc Inerney-new york westPrince Knight-new york eastPaul Henri-north new jerseyGOALKEEPER COACHING TRAINING IN NEW JERSEY – CENTRAL Welcome PackageJ4K Gloves/Academy T-Shirt (Glove Style and Color may Vary) Need Sizing Assitance? For Assistance with sizing, Please visit the Link below Gloves - Select Size4567891011 Shirt Size - Select Size Youth Medium/2XsAdult SmallAdult MediumAdult Extra Large Parent/Guardian ConsentI hereby consent to any and all health services necessary by Just 4 Keepers staff to refer my child for consultation to any licensed medical specialist or to any area Emergency Room. I give authority and power to any such physician/surgeon to render any and all health services that may be deemed necessary or advisable. I authorize the Just 4 Keepers Director to accompany my child and sign permit forms required by the Medical Counter. I understand in case of serious accident or illness every effort will be made to contact me. I understand I will be responsible for any costs or care provided. Parent/Guardian First Name Last Name Do You Consent YesNo Date of Consent Comments or Questions ￩ ￫ x ×Share this:PrintFacebookLinkedInTwitterPinterestLike this:Like Loading...
