AJAX-PICKERING - SUMMER 2012 3 on 3 HOCKEY TEAM ENTRY
Team
Name: ________________________________________________________________________________________
Team Colours: (team provides sweaters) __________________________________
Division (Tyke, Novice,
Atom, Peewee, Bantam )___________________________________
Team
Rep Name________________________________________
Team Rep.Address:________________________________________________________________________________
City________________Postal Code__________
Home Phone:___________________________ Bus: ___________________________
E-mail:_________________________________________________________
(for standings/newsletters/schedule changes etc)
TEAM REP HEALTH CERTIFICATION: Upon signing this application, the team rep certifies that all players are in good
normal health, are properly equipped (full hockey equipment mandatory) and have 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.
TEAM REP 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 members of this team. 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 explained these risks to the parents of all team member.
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 member of the team 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 the team rep having the legal right to assume the conditions above on behalf of the team players named on the roster
sheet. My signature below also indicates that I have thoroughly read and agree to all of the terms above.
TEAM
REP SIGNATURE ________________________
DATED THIS ________DAY OF ________, 2012
NOT
VALID WITHOUT ROSTER SHEET INCLUDING SIGNATURES AND PAYMENT
TEAM ENTRY FEES: $2790.00 ($2389.39 & $310.61 = $2790.00)
MAIL TO: AJAX PICKERING 3 ON 3 SUMMER HOCKEY, 106 Holliday Dr, Whitby ON L1P 1G5
No in-person deliveries - no refunds
