Ajax Pickering Summer Minor Hockey League

On Line Registration (REP Individual players only)

Enter todays date (mmm-dd-yy)  * required

Player's Name (first, last)  * required

Parent's e-mail address  * required

Street address  * required City  * required Postal Code  * required Telephone Number (xxx-xxx-xxxx)  * required Player's year of birth  * required Describe any medical issues we should be aware of I would like to play with (name one player only - no guarantees) Check the level of hockey played in the winter 11-12 season  *required Boys AAA Boys AA Boys A Girls AA or A Preferred position (no guarantees) Forward Defence Goal Parent - Are you willing to coach the team? Yes - Coach Yes - Assistant Coach No Parents:  Are you willing to sponsor your child's team? (for info, including how your child can play "free", - click on "sponsorship" link above) Yes - please contact me for sponsorship details No PLAYER HEALTH CERTIFICATION: My acceptance selection certifies that the player is in good normal health, is properly equipped (full hockey equipment mandatory) and has no abnormal handicaps. My acceptance selection also confirms I have the authority to complete this application on behalf of the child named above. Registration is conditional on accepting these terms by checking the appropriate box below. I accept these terms I do not accept these terms and understand that my registration will not be accepted PARTICIPANT WAIVER AND INFORMED CONSENT: To whom it may concern: I, as the submitter of this form, authorize The Ajax Summer Minor Hockey League and/or 771227 Ontario Ltd. and/or Town of Ajax 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 (named above). I have been warned and informed via this form 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 acceptance selection indicates my informed consent to allow my child to participate knowing the risks involved. And I hereby indemnify and save harmless the The Ajax Summer Minor Hockey League and/or 771227 Ontario Ltd. and/or Town of Ajax 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 my child (named above) while participating in any activity or facility operated by The Ajax Summer Minor Hockey League and/or 771227 Ontario Ltd. and/or Town of Ajax. My acceptance selection indicates that I am a Parent/Legal Guardian/Adult participant having the legal right to assume the conditions above on behalf of the player named above. My acceptance selection also indicates that I have thoroughly read and agree to all of the terms above. Registration is conditional on accepting these terms. I accept the terms above I do not accept these terms and understand that my registration will not be accepted PLAYER/PARENT/GUARDIAN CONDUCT: The Ajax Summer Minor Hockey League and/or 771227 Ontario Ltd. operates on Municipal property with the permission of the Town of Ajax. 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 as well as respecting and abiding by League rules and decisions. My acceptance selection indicates acceptance by the Player, Player's Parents and/or Player's Guardians. Registration is conditional on accepting these terms by selecting the appropriate box below. I accept the terms above I do not accept these terms and understand that my registration will not be accepted PAYMENT INFORMATION Credit card type VISA Mastercard Credit card number  * required Expiry date (mm-yy)  * required 3 digit security code - (usually on the back of the card above the signature strip)  * required Name (exactly as it appears on the card)  * required Address (enter the complete billing address only if different than above address provided) I consent to charge my credit card $289.00 ($238.93 & HST) for Summer hockey registration.  *required I consent to the charge. I do not accept these terms and understand that my registration will not be accepted