Ajax Pickering Summer Minor Hockey League

On Line Registration (3 on 3 Team Entry)

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

Name of Person Submitting the Team (Team Rep) (first name, last name)  * required

Team Rep E-mail address  * required

Team Rep Street address  * required City  * required Postal Code  * required Team Rep Telephone Number (xxx-xxx-xxxx)  * required I wish to enter a team at this level: (enter the level played during the 11-12 winter season) Atom Rep Pee Wee Rep Bantam Rep Midget Rep Team Name Team Colours - (subject to availability - don't purchase jerseys until colour availability is confirmed - first entries get best choice)  * required Team Roster:  I understand that I must complete and submit a team roster including player and parent/guardian signatures prior to the first game.  Only players on the roster may play. I accept the terms above. I do not accept these terms and understand that my registration will not be accepted PLAYER HEALTH CERTIFICATION: My acceptance selection certifies that the players are in good normal health, are properly equipped (full hockey equipment mandatory) and have no abnormal handicaps. My acceptance selection also confirms I have the authority to complete this application on behalf of the players on the team named above. Registration is conditional on accepting these terms by checking the appropriate box below. I accept and have the authority to accept these terms on behalf of the players and parents/guardians 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 any child of the team (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 and also my authority to allow all members of the team 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 any members of the team (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 the Team Rep and have the permission of the Parent/Legal Guardian having the legal right to assume the conditions above on behalf of the  team members. My acceptance selection also indicates that I have thoroughly read and agree to all of the terms above. I understand that registration is conditional on accepting these terms. I accept and have the authority to accept these terms on behalf of the players and parents/guardians 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 and have the authority to accept these terms on behalf of the players and parents/guardians 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 $2890.00 (including $332.48 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