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PARENTAL/GUARDIAN

CONSENT AND WAIVER OF RESPONSIBILITY

Norwalk Goalkeeper Academy

I agree that on behalf of the enrolled student named on this application form, Norwalk High School and/or the Norwalk Goalkeeper Academy and/or their staff, coaches, or employees will not be held responsible for any injury, accident or loss of property, however caused. It is further agreed that all risks involved in participation in said camp are assumed by the student and his/her parent or guardian, who are also responsible for the medical fitness of the enrollee and for all medical costs incurred in case of injury while in attendance at the Norwalk Goalkeeper Academy. I have read the above and consent to the terms as stated.

Costs:

The academy fee is $100. This includes goalkeeper gloves and a goalkeeper training jersey. The full fee must accompany your application, which should be received by June 8, 2009, as registrations received after that date or up to the beginning of the academy will be an additional $5.

Norwalk Goalkeeper Academy - Coed

Academy members:

*All members should be in good physical health as they will experience potentially strenuous times of activity. *All members must supply their own health and accident insurance coverage. *Academy enrollment is limited and given on a first-come first-serve basis.

Location:

Parent's/Guardian's Signature Date

EMERGENCY CONTACT: Name of Person

McAninch Sports Complex 200 Wright Road Norwalk, IA 50211

The complex is located on the south side of Norwalk, west on Wright Road off of Hwy 28. Turn west at the mini storage facility into the Norwalk Business Park. Proceed to the end of the street and enter the complex parking lot on the south side of road

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Telephone Number

June: 10, 17, 22, 24 July: 8, 15, 22, 29 6-7pm

RETURN THIS FORM WITH YOUR PAYMENT

Norwalk Goalkeeper Academy - CoEd

Academy Staff

Coach Jeremy Ward Played: Norwalk High School '03 - '06 Captain 2005, 2006 Simpson College '06 - '08 Coached: Norwalk High School 2009 Simpson College Youth Camp '06 - '08 Assistant Coaches Ben Smiley-2008 First team All-State Goalkeeper and Current High School Goalkeepers Academy Sessions 6-7pm June: 10, 17, 22, 24 July: 8, 15, 22, 29

Norwalk Goalkeeper Academy - CoEd

Name _____________________________ Address ___________________________ City _____________ Zip _____________ Phone ______________________ Email ______________________ School _____________________ Grade (2009/10) _____________ Age ____________ Glove Size: _________________

2007 State Champions 2004, 2006, 2008 runners-up 2005 quarter-finals

Goalkeeping Aspects Covered:

· · · · · · · ·

Jersey Size (adult size) S M L XL Cost: $100 per player. Make checks payable to:

Norwalk High School Boys Soccer

EQUIPMENT REQUIRED

*Soccer players are required to provide and wear shin guards. *Players must provide shoes, soccer shoes are suggested but not mandatory. If soccer shoes are new, please bring along another pair of shoes in case of blisters. *Players are also asked to bring a water jug and an extra pair of socks.

Catching Diving Cutting out crosses Dealing with breakaways Distribution Positioning Footwork Dealing with high balls

Mail to:

Norwalk High School Boys Soccer c/o Dustin Kralik 2402 57th Street Des Moines, IA 50310

Application Deadline: June 8, 2009

If you have any questions, please feel free to contact Coach Dustin Kralik Coach Jeremy Ward (515)314-8416 or [email protected] (515)490-3427 or [email protected]

RETURN THIS FORM WITH YOUR PAYMENT

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