Mail-In Registration Form House League/AE

Use Control-P to Print - Complete Form and Mail to:
AJAX PICKERING SUMMER HOCKEY, 23 Divine Dr, Whitby ON  L1R 2T4

Player Name: _________________________________________________Birthday:yy-mm-dd _________________

Address:_____________________________________________________City________________Postal Code_________

Phone:______________________________ E-mail (required)___________________________________________

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 ________, 2019 NOT VALID WITHOUT SIGNATURES AND PAYMENT

FEES: $269.00  ($259.00 & $10.00 refundable sweater deposit=$269.00)

MAIL TO: AJAX PICKERING SUMMER HOCKEY, 23 Divine Dr, Whitby ON  L1R 2T4
(no in-person deliveries please, mail only) (no refunds permitted)