Print the form, complete and mail to the address below

ST. CATHARINES REP 3 on 3 HOCKEY

Summer 2012 Application Form (for AA-AAA players only)

Name: ________________________________________________________________________________________

Division: Please circle (Atom (4 on 4),PeeWee, Bantam, Midget)  Date of Birth:_________________

Preferred Position_______________ Level (circle) "AA" "AAA" Organization____________________________________

Address:________________________________________________________________________________

City________________Postal Code__________

Home Phone:___________________________ Bus: ___________________________

E-mail:_________________________________________________________
(for standings/newsletters/schedule changes etc) 

Health Card #______________________________Any medical conditions?_______________________

PLAYER HEALTH CERTIFICATION: Upon signing this application, the parent/guardian certifies that the player is in good normal health, is properly equipped (full hockey equipment mandatory) and has no abnormal handicaps.
PLAYER/PARENT/GUARDIAN CONDUCT: The St. Catharines Summer Minor Hockey League and/or DJ Management operates on Municipal property with the permission of the City of St. Catharines. To this end, players, parents/guardians and participants will respect the facilities and grounds and will abide by the rules set forth by the facility and staff.

WAIVER AND INFORMED CONSENT: To whom it may concern: I, the undersigned, authorize The St. Catharines Summer Minor Hockey League and/or DJ Management and/or City of St. Catharines and/or anyone acting on their behalf to acquire necessary medical aid that may be required as a result of any accident or injury which may be sustained by my child. I have been warned and informed via this document that insurance coverage is not provided and there are serious physical risks associated with hockey, including, but not limited to falls and/or collisions with stationary objects, other players, skates pucks and sticks. My signature below indicates my confirmation that I have understand these risks.  And I hereby indemnify and save harmless the The St. Catharines Summer Minor Hockey League and/or DJ Management and/or City of St. Catharines and/or anyone acting on their behalf from any and all actions, claims and demands for damages, loss or injury however arising which here to after may have been sustained by (enter childs name)_______________________________ while participating in any activity or facility operated by The St. Catharines Summer Minor Hockey League and/or DJ MAnagement and/or City of St. Catharines. My signature below indicates that I am the parent/guardian having the legal right to assume the conditions above on behalf of the player named above.   My signature below also indicates that I have thoroughly read and agree to all of the terms above. 

PARENT/GUARDIAN SIGNATURE ________________________

DATED THIS ________DAY OF ________, 2012
NOT VALID WITHOUT SIGNATURE AND PAYMENT

INDIVIDUAL ENTRY FEES: $283.00 +HST = $319.00