Name:

Email:

Address:

City: Province: Postal Code:

Work Telephone: Home Telephone: Emergency Telephone:

Age: Birthdate:

Level of hockey last played: eg: Initiation/Atoms/Pee Wee/Peter Puck

(If classes taken in 2009-2010)

Medical Number:

Name of Parent/Guardian:

Group 1 Group 2 Group 3

WAIVER

I understand that hockey and the sports activities of a Hockey Camp involve inherent and other risks of injury. I voluntarily agree to expressly assume all risks of injury which may result from my child's participation in the Peter Puck Hockey Camp.

I agree to release Dianna Hartnell d.b.a. Dolson's Peter Puck Hockey Camp, its employees, instructors, owners, affiliates and agents from all liability for personal injury, property loss and damage, including all liability which results from the negligence of the Dolson's Peter Puck Hockey Camp, employees, instructors, owners, affiliates and agents.

I, the undersigned, verify that I am the parent or guardian of the child participating in the Dolson's Peter Puck Hockey Camp and state that I have read and understand the terms of this liability release agreement.

Accept

Decline