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***PLEASE NOTE: PAYMENT OR DEPOSIT IS REQUIRED TO RESERVE YOUR SPOT. PAYMENT CAN BE COMPLETED ONLINE AFTER SUBMITTING THIS SIGN UP FORM. ALTERNATIVELY YOU CAN MAIL IN YOUR PAYMENT TO US.***
Today's Date:
Student's Name:
First Name:
Last Name:
Address:
Street:
City:   State:
Zip Code:
Father's Name:
Mother's Name:
Phone Numbers:

Home Phone: - -
Dad's Cell phone: - -
Mom's Cell phone: - -
Emergency Phone: - -
Other phone Number: - -

E-Mail Address:
Date of Birth:
Month Day Year
Height:
Weight:
Gender:
Male Female
Present School Name:
Present School Grade:
Hockey Experience / Number of Years Played:
Current Team(s), if any?:
Position Played, if any?:
Health Insurance Company, if any?:
Have you skated with Garry before?:
Yes No
If Yes, where did you last attend class (city and rink):
If Yes, when did you last attend (month/year):
How did you hear about us:
Camp(s) attending:
VT-1 VT-2 H-1
FX-1 FX-2 FX-3
BG-1 BG-2
PS-1 PS-2 MV-1 MV-2
ELITE-1 Season-Long Saturday Morning
ELITE-2 Season-Long Saturday Morning
SS-1 Split Season Wednesday Night
Medical Release:
I acknowledge the applicant is in good health and is able to participate in the physical activity of a vigorous program. In the event my child is injured during absence of parent or legal guardian, I give my permission for the person in charge to seek medical attention.

Release of Liability/Acknowledgment of Risk:
Upon entering the Garry Hebert Hockey Event, I/We understand that participation in the sport of ice hockey, as well as in this event, constitutes a risk to me/us or serious injury, including permanent paralysis or death. I/We voluntarily and knowingly recognize, accept and assume the risk and release Garry Hebert, his sponsors, event organizers, staff members, the skating facility and officials from any liability therefore.
 Checking this box acts as your signature and your agreement with the terms and conditions of the medical release and release of liability/acknowledgment of risk as shown above.
 

 

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Phone: