Indiana Goalkeeper Academy Medical Release Form
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Indiana Goalkeeper Academy Medical Release and Waiver
To be signed by parent or guardian:
On behalf of the applicant, I release Indiana Goalkeeper Academy (IGA), Gary Yohe, and IGA
Staff and sponsors from all applicant claims arising from participation in the camp or any related
training or coaching sessions. I certify that the applicant will list all medical conditions below in the
space provided.
Name of participating minor: ____________________________________________________
Date of Birth (DD/MM/YR)________________________________________________________
Address______________________________________________________________________
City _________________________________________________________________________
Postal Code __________________________________________________________________
Parent Name(s)________________________________________________________________
Home phone (

)___________ Cell # 1 (

)______________ Cell # 2 (

)_______________

Medical Conditions

_______________