| Program |
_________________________________________ |
| Program Date |
_________________________________________ |
| Name: |
_________________________________________ |
| Address: |
_________________________________________ |
| City: |
_________________________________________ |
| Postal Code: |
_________________________________________ |
| Home phone # |
_________________________________________ |
| Email (if applicable) |
_________________________________________ |
| Fax (if applicable) |
_________________________________________ |
| Health card number: |
_________________________________________ |
| D.O.B. |
_________________________________________ |
| Family Doctor: |
_________________________________________ |
| Doctor's phone number: |
_________________________________________ |
| Hockey Team |
_________________________________________ |
| City |
_________________________________________ |
| Position |
_________________________________________ |
| Rep/HouseLeague |
_________________________________________ |
| Other sports |
_________________________________________ |
to participate in _______________________________________________,
and do hereby agree to release all program staff and volunteers from any personal
injury or harm and/or damage to or loss of personal items incurred during the
program. It is understood that the program is designed to offer a safe and supervised
environment.
Name(s) please print: _________________________________
Signature(S)
: _______________________________________
