Please complete this form and mail along with check or money order to:
HOCKEY AND DAUGHTERS SKILLS CAMP
TROY G. WARD
2208 Spring Street
Cross Plains, WI 53528
HOME PHONE: (608)798-4767
---------------------Enrollment Form---------------------
COST: $595.00.
P L E A S E P R I N T!!!!! PLEASE PRINT!!!!! PLEASE PRINT!!!!! Please make this legible.
It would be greatly appreciated if you fill this form out completely and fill a form out for each individual attending. THANK YOU!
ATTENDING: ____AUGUST session (8/16-20/06)
PARENT:
How did you find out about this camp? Web Site _______ Referral from _______________ Printed Advertisement ______________
I am the: Mom ________ or Dad _________
My Occupation is: ________________________________________________
Name ___________________________________________________________
Address _________________________________________________________
City _____________________ State ________________Zip _______________
Home Phone (_______) ______________________
Cell Phone (________) ______________________
Work Phone (_______)_______________________
Email Address: _____________________________
Age _____________ Do you or did you play Hockey? _____________
Where? _____________________ When?______________
Position _____________________
Are you a coach? _____________ What Level? _________
Insurance Carrier __________________ Policy Number_________________
Emergency Contact _______________________________________________
Emergency Phone Number (________) _________________________
Jersey size, please check one for child and one for parent:
Youth _____Small _____Medium _____Large
Parent (Jersey's will be men's sizes) _____Small _____Medium _____Large _____X-Large _____XX-Large
SPECIAL REQUESTS: Please list families you want to be near in the dorms and/or locker rooms. We try to accommodate all requests, but this isn't always possible. ______________________________________________________________________________
__________________________________________________________________________________________________________________
CHILD:
Girl _______ or Boy ________
Name ___________________________________________________________
Address _________________________________________________________
City _____________________ State ________________Zip _______________
Home Phone (_______) ______________________
Email Address: _____________________________
Age ________ Date of Birth___________________
Height _______ ft. _______ in. Weight __________
Position _____________________ Team Level __________________________
Insurance Carrier ____________________Policy Number ___________________
Emergency Contact _________________________________________________
Emergency Phone Number (________) __________________
Acknowledgment of Risk and Release
RELEASE OF LIABILITY. As a Participant and Parent of a Participant child, I hereby acknowledge and agree that hockey activities are, by their inherent nature, dangerous and represent a substantial risk of personal injury, property damage and/or death to participants. On behalf of myself and my child (identified below), I SPECIFICALLY ACKNOWLEDGE that our participation in a Hockey and Daughters camp or activity, subjects me and my child to substantial and serious risk of property damage, personal injury and/or death. Recognizing such hazard and in consideration for being permitted to participate in such activities, on behalf of myself and my child, I ASSUME ALL SUCH HAZARDS AND RISKS, AND FULLY WAIVE, RELEASE AND FOREVER DISCHARGE Hockey and Daughters, its officers, directors, coaches, employees, agents, and representatives, as well as all sponsors of the program, their subsidiaries and affiliated companies, and their respective officers, directors, employees, agents and representatives, from and against any and all claims, demands and liabilities which I or my child may have, now or in the future, known or unknown, foreseen or unforeseen, future or contingent, which arise or result from, or are in any way connected with our participation in the said activities. I FURTHER COVENANT AND AGREE for myself and on behalf of my child, that I will not commence or prosecute any action, suit or other proceeding against any of the parties so released and discharged.
Print Child's Name____________________________________________________________
Signature of Parent or Guardian________________________________ Date_____________
Signature of Parent or Guardian________________________________ Date_____________ |
