SPORTS CAMPS & CLINICS

Camp Registration

Hockey Camp

Coupon code:

Participant Information

First Name:
*
Last Name:
*
USA Hockey Number:
*
Email:
*
Phone:
Cell Phone:
School Name:
*
Gender:
*
Birth Date:
*
(YYYY-MM-DD)
Division Entering this Fall:
*

Registration Information

Hockey Camp *

Option Availability Cost
Saturdays - Sept. 14, 21, 28 and Oct. 5
Available $80.00

Interested in Goaltender Training *

Option Cost
No
$0.00
Yes
$0.00

Total Price

Medical Information

Notice

Dordt College does not employ or provide nursing or medical personnel on campus during academic or athletic camps. Medical emergencies, if any, are addressed through local emergency medical response personnel.

Emergency Authorization/Consent to Medical Treatment

By signature below, I authorize Dordt College and its representatives, if present, to provide to my child, through medical personnel of their choice, customary medical assistance, transportation, and emergency medical services should my child require such assistance, transportation, or services as a result of injury, illness or damage while participating in or related to my child's participation in camp. This consent does not impose a duty upon Dordt College or its representatives to provide such assistance, transportation, or services.

Financial Responsibility

By signature below, I accept financial responsibility for all medical treatment provided to my child at Dordt College's request. I also understand and acknowledge that Dordt College is not responsible for administering any medications to my child.

Applicable Law

Because Dordt College is located in the State of Iowa, and in order to provide certainty in the law to be applied to the construction of this instrument, this Consent shall be governed, construed and enforced in accordance with the law of the State of Iowa.

Physician's Name:
*
Physician's Phone:
*
Insurance Provider:
*
Insurance Policy ID:
*
Primary Name on Insurance Policy:
*
Insurance Plan ID:
Describe any allergies:
Describe any medical conditions:
List any medications currently taken:
Parent/Guardian Signature (full name):
*

Parent/Guardian Information

Full Name:
*
Address Line 1:
*
Address Line 2:
City:
*
State:
*
Zip/Postal Code:
*
Country:
*
Phone:
*
Email:
*

Alternate Emergency Contact

Full Name:
*
Phone:
*
Cell Phone:
Relationship to participant:
*

Credit Card Information

Credit Cards
Card Type:
*
Card Number:
*
CVV/CVC:
*
Expiration Date:
*

* I give permission to Dordt College to take and use photos, videos, and audio recordings of the participant(s) for educational, advertising and promotional materials unless I contact the public relations office at public-relations@dordt.edu to specifically opt out.

* I agree to abide by the rules set forth in the Sports Camp Manual.

* I consent to the Release of Liability, Waiver, and Indemnification.