Goaltender’s name: __________________________________________________

Mother’s name: ___________________Father’s Name: _____________________

Address: ___________________________________________________________

City: ________________________________ State: _____ Zip: _______________

Home Phone: _______________________________________________________

Mother’s Cell phone: ______________ Father’s Cell phone: __________________

Fax: ____________________________ E-mail: ___________________________

Age: __________________________ Birth Date: __________________________

Age Group: □ Mite □ Squirt □ Peewee □ Bantam □ Midget □ High School □ Junior

Level: □ In-House □ B □ A □ AA □ AAA

Youth Hockey Organization/H.S.: ______________________________________

Expected Team/Level – 2008-09: ______________________________________

Years Played Goaltender: _____________________________________________

Height: _________________ Weight: _________________ □ Male □ Female

Jersey Size: □ Youth L □ Men’s M/L □ XL □ Goalie Cut

USA Hockey Membership ?: __________________________________________

Health Insurance Provider & Plan #: ____________________________________

Emergency Contact: __________________________ Phone: ________________

All Textbook Goaltending students will be grouped based on a combination of age and skill level, which is subject to the director and instructors’ discretion. Textbook Goaltending also retains the right to terminate any student if it’s in the best interest of the student, other students or the school.

In the event of a student’s cancellation, all payments will be credited towards future Textbook Goaltending registration fees. There will be no cash refunds.

The tuition for Textbook Goaltending 2008 is once again $525. A Family Discount of $100 applies - $950 for 2 students from one family.

Amount Enclosed: $________________ Family Discount: □

Signature of Parent/Guardian: _________________________________________