Mail In REP 3 on 3 TEAM ENTRY
Use Control-P to Print - Complete Form and Mail to:
AJAX PICKERING SUMMER HOCKEY, 23 Divine Dr, Whitby ON L1R 2T4
Team REP Name:________________________________________
Team Rep Address:_____________________________________________________
Phone:______________________________ E-mail (required)___________________________________________
Calibre of hockey last played (circle):
BOYS A, AA, AAA
Team Name: ________________________________________________________________________________________
Team Colours: (team MUST provide own sweaters) __________________________________
Division (Tyke, Novice, Atom, Peewee, Bantam )___________________________________
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 members. 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 ________________________
NOT VALID WITHOUT ROSTER SHEET INCLUDING SIGNATURES AND PAYMENT
TEAM ENTRY FEES: $2890.00
DATED THIS ___DAY OF ________, 2019 NOT VALID WITHOUT SIGNATURES AND PAYMENT
MAIL TO: AJAX PICKERING SUMMER HOCKEY, 23 Divine Dr, Whitby ON L1R 2T4
(no in-person deliveries please, mail only) (no refunds permitted)