| HOBOMOCK ARENAS POWER SKATING & STICKHANDLING APPLICATION PEAK PERFORMANCE PROGRAM APPLICATION Spring/Summer 2011 Name _______________________________________ Telephone__________________ Street ____________________________________Age_________ Birthdate __________ City/Town_______________________ State ____________________Zip_____________ Parents Name(s) __________________________________________________________ Parents email address______________________________________________________ Previous Hockey Experience__________________________________________________ ________________________________________________________________________ Youth Hockey Organization_______________________________________________________ Registering For: check all that apply Amount Paid ________check #________ [ ] Power Skating 5 weeks prepaid $35**** [ ] Session #1 Stickhandling April 28 - June 16 (8 weeks) $72 [ ] Session #2 Stickhandling June 23 - August 25 (10 weeks) $90 [ ] SPECIAL-- both Stickhandling Sessions April 28 - August 25 (18 weeks) $144 [ ] SUMMER PEAK PERFORMANCE PROGRAM -- All Power Skating and Stickhandling Sessions April 26 -August 25, 2011 (18 weeks) $255 Make Checks Payable to: Hobomock Arena P.O. Box 536, Pembroke, MA 02359-0536 INSURANCE /WAIVER INFORMATION (MUST BE COMPLETED TO PARTICIPATE) MEDICAL/ INSURANCE COMPANY___________________________________________________________________________________ In consideration of participating in any Hobomock Sports Center, Inc. activity, including Basic Skills, and Ice Hockey instruction, I represent that I understand the nature of the activity and that I and/or my minor child am qualified, in good health and proper physical condition to participate in such activity. I acknowledge that if the conditions are unsafe, I and/or my minor child will immediately discontinue participation in the activity. I fully understand that ice skating/ ice hockey involves risks of serious bodily injury, including permanent disability, paralysis and death, and that these and other risks may be caused by my own actions, or inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the Releasees named below; and that there may be other risks either not known to me or not foreseen at this time; and I fully accept and assume all such risks and all responsibility for losses, costs, and damages I incur as a result of my participation in the activity. I hearby release, discharge, and covenant not to sue the Hobomock Sports Center Inc.., their respective administrators, directors, agents, officers, volunteers, and employees, or other participants ( each considered one of the Releasees herein) from all liability claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue operations; and I further agree that if, despite this release, waiver of liability, and assumption of risk, I, or anyone on my and/or my minor child’s behalf, makes a claim against any of the Releasees, I will indemnify, defend, save, and hold harmless each of the Releasees from any loss, liability, damage, or cost which may incur as the result of such claim. I have read this release and waiver of liability, assumption of risk and indemnity and fully understand it. Signature of Participant or Parent/legal Guardian ( If participant is under age 18) ___________________________________________________________________ Date _____________________ |