AJAX-PICKERING SUMMER MINOR HOCKEY LEAGUE
For House League or AE Midget/Juvenile players only
Player Name: ________________________________________________________________________________________
Date of Birth:(year/month/day)___________________________________
Address:________________________________________________________________________________
City________________Postal Code__________
Home Phone:___________________________ Bus: ___________________________
E-mail:_________________________________________________________
(for standings/newsletters/schedule changes etc)
Any known Allergy/Medical conditions (specify)___________________________________________
Please circle appropriate choice:
GOALTENDER DEFENCE FORWARD
Parents: Are you willing to coach or sponsor
?
(please circle) COACH ASS'T COACH SPONSOR
Calibre
of hockey last played:
BOYS HOUSE LEAGUE BOYS SELECT/AE (note: male A, AA, AAA players
not accepted, see the 3 on 3 program)
GIRLS HOUSE LEAGUE
GIRLS B,BB,C (note female A,AA players not accepted, see the 3 on 3 program)
I would like to play with:_______________________________________
(name one player only - no guarantees, -multiple requests for one player-league decision final )
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 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.
PARTICIPANT WAIVER
AND INFORMED CONSENT: To whom it may concern: I, the undersigned, 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. 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
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
Print Child's name here ______________________________________
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 signature below 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 signature below also indicates that
I have thoroughly read and agree to all of the terms above.
PLAYER SIGNATURE _______________________PARENT
SIGNATURE______________________________
DATED THIS ________DAY OF ________, 2011 NOT VALID WITHOUT SIGNATURES
AND PAYMENT
FEES: $269.00 ($229.00 & $40.00 HST & $10.00 refundable
sweater deposit=$269.00)
MAIL TO: AJAX PICKERING SUMMER HOCKEY, 106
Holliday Dr. Whitby, ON L1P 1G5
(no in-person deliveries please, mail only) (no refunds permitted)
