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YOUTH SESSION 1

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REGISTRATION - High School Fall Skills Camp

The camp cost is only $125 per fall session!

SUBMIT FORM BELOW

MAIL CHECKS PAYABLE TO:

Laconia Ice Arena

Attn: Training Camp Hockey

468 Province Road Laconia, NH 03246 TRAINING CAMP HOCKEY REGISTRATION

PARTICIPANT REGISTER HERE & SUBMIT!

Participant's First Name *Last Name* *Street Address* *Address (cont.)* *City* *State/Province* *Zip/Postal Code* Parent's Primary E-mail *Parent's Home Phone* Parent's Work Phone *Parent's Cell Phone* *Any additional contact information you wish to supply (secondary e-mail, alt. phone, or special medical instructions, etc.)* Select any of the following options that apply: Register me for the Fall High School Skills Camp! Level for next season? Please provide the following information: *Date of Birth* Age During Camp dates Position? Shot? How did you hear about us? How would you rate your level of hockey experience? What is your Team For the upcoming season?: PLAYERS WILL BE ASKED TO SIGN THIS WAIVER PRIOR TO CAMP (A PRINTABLE COPY WILL BE EMAILED TO YOU) Training Camp Hockey ATHLETE WAIVER & MEDICAL DISCLOSURE ATHLETE NAME: ______________________________________ DOB: ____ / ____ / ____ Age: ______ Gender:__________________ Address: __________________________________________ Home Phone: __________________ City: _________________________________ State:_____ Zip:_____________ Current Team:___________________________________ Father’s Name: ________________________________________ Father’s Cell Phone: ___________________________ Mother’s Name: _______________________________________ Mother’s Cell Phone: __________________________ Other emergency Contact: ____________________________________________ Phone Number: _______________________________ WAIVER, EMERGENCY MEDICAL RELEASE and CONSENT I/We __________________, understand that training for competitive sports and all the other activities relating to Training Camp Hockey, The Laconia Ice Arena, The Laconia Leafs and its programs are dangerous and physically demanding activities and that serious personal injury to the above athlete is possible. I/We acknowledge and accept the inherent dangers of physical injury to participants in these activities, and hereby agree to allow the above athlete to participate in all such activities. I/We herby release Training Camp Hockey, The Laconia Ice Arena, The Laconia Leafs and any other employees of the camp and agree to hold all said parties harmless from any and all claims, demands, causes of action, and/or attorney fees arising out of or in any way related to any personal injury or property damage sustained by/to the above athlete while involved, spectating, or being transported to and from Training Camp Hockey, The Laconia Ice Arena, and Laconia Leafs activities. I/We have read and understand this release and voluntarily, willingly and knowingly have executed this release as evidence of our agreement to all of its terms. Parent/Guardian Signature: _______________________________________ Date: _______________ I/We the undersigned, as parent(s) and/or legal guardian(s) of the above athlete recognize that medical treatment may become necessary during the above athlete’s travel and participation in the Training Camp Hockey, The Laconia Ice Arena, and The Laconia Leafs programs. In the event of an emergency requiring treatment, surgery or the administration of other medical services, permission is granted by ____________________________, who is the parent and/or guardian of _________________________, a minor, to Training Camp Hockey, The Laconia Ice Arena, The Laconia Leafs and Staff to act on his/her behalf, should attempts to contact the above named person(s) prove to be unsuccessful. I/We herby empower the coaches and staff of Training Camp Hockey, The Laconia Ice Arena, The Laconia Leafs to authorize on my/our behalf recommended medical treatment by any doctor, emergency medical technician and/or paramedic that is advisable for the care and treatment of the above named athlete. This authorization is complete in and of itself and is fully operative upon my signature for the duration of the above athlete’s participation in Training Camp Hockey, The Laconia Ice Arena, and The Laconia Leafs programs. Parent/Guardian Signature: _______________________________________ Date: _______________ IMPORTANT MEDICAL HISTORY & INSURANCE INFORMATION Family Physician’s Name: Phone: ________ Allergies: (food, drugs, other) Current Medications: List any pre-existing conditions (asthma, epilepsy, diabetes, head injuries/concussions, fractures, surgeries, severe sprains/strains, hemophilia) and explain: __________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Medical Insurance Company: Phone: _________________ Policy Number: __________________________________ Policy Holder’s Date of Birth: _________________________ This form must be entirely completed and returned to TCH in order to take part in Camp!

PLAYERS WILL BE ASKED TO SIGN THIS WAIVER PRIOR TO CAMP