Registration form identification camp cost: $25. 00



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REGISTRATION FORM

IDENTIFICATION CAMP

COST: $25.00 (Including HST)

The registration fee will guarantee the participant a total of 1.5 hours of ice time.

Please complete registration form and forward along with payment to: Make cheque payable to:

ATLANTIC HOCKEY GROUP

P.O. Box 1481, Moncton, N.B., E1C 8T6

Fax: (506) 854-8200 Tel.: 1 (888) 421-0000

[ ] VISA [ ] Mastercard [ ] AMEX

# __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Expiration date: ____ / ____

Card Holder Name: ____________________________

Cancellation

Players who voluntarily leave a tryout session or are expelled for disciplinary reasons will not be refunded.



Program: Nova Scotia AAA Series

Team:




PLAYER INFORMATION


Name: _______________________________________

(Please Print)

Mailing Address: ______________________________

City: ________________________________________

Province: _________ Postal Code: ______________

E-mail: _____________________________________

Tel No: (Home) _______________ (Work) __________

Age: _________ Date of Birth: __________________

(Day / Month / Year)

Father: _________________ Mother: ______________

Medicare Number: ____________________________

Current Team : _______________________________

Position: __________ Shoots: ____ Left ____Right

I / we hereby release Charlie Bourgeois Hockey School Inc., its officers, employees and agents from all liability, claims, causes of actions of any kind whatsoever, in respect of damages I / (my child) may suffer as a consequence of my child sustaining personal injury, death or property damage or loss while participating in programs and activities of the Charlie Bourgeois Hockey School Inc.

And I / we do hereby agree to indemnify and hold harmless Charlie Bourgeois hockey School Inc., its officers, employees, or agents from any and all claims, demands, causes of actions of any kind whatsoever, including those involving negligence on the part of Charlie Bourgeois Hockey school Inc. or any of its officers, employees or agents that may be made or initiated by, or on behalf of my child, arising out of or connected with my said child’s preparation for or participation in any of the Charlie Bourgeois Hockey school Inc. programs of activities.



___________________________

Authorized by Parent or Guardian

For office use only

Date Deposit Balance



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