Registration form please complete and mail or fax application form to: atlantic hockey group, P. O. Box 1481, moncton, nb, E1C 8T6
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3vs3 Cross Ice Tournament Moncton 4-ice Center December 27th & 28th 2015 Name (Please Print):_________________________________________________________________________ Mailing Address:_____________________________________________________________________________ City: ______________________________ Province / State: ____________ Zip / Postal Code: _______________ Home Phone: ( ______ )____________________________ Bus: ( ______ )____________________________ E-mail: ____________________________________________________________________________________ Male [ ] Female [ ] Date of Birth (Day / Month / Year): ______________________________ Father's Name: ___________________________________ Mother: ___________________________________ Current Division Played: _____________________ [ ] 1st year [ ] 2nd year Level: AAA [ ] AA [ ] A [ ] B [ ] Recreational League [ ] Position: ______________________________ Coach's Name: _______________________________________ Medicare Number: ___________________________________________________________________________ Please send correspondence: [ ] English [ ] French To be instructed in: [ ] English [ ] French Individual registration $50.00 (includes HST) Credit Card Payment [ ] Visa [ ] Mastercard [ ] American Express #__________________________________________________
I / we do 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 or activities.
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