Personal Information      
        Name:      
      *      
        Street Address:   City:  
       
        State/Province: Zip/Post Cd:    
         
        Telephone:   Cell:  
         ( ) -    ( ) -
        Email:      
      *    
        Birth Date:   Height:   Weight:
      * MM  * DD  *YYYY   * Ft * In * lbs
Position Goalie      Center LWing RWing LDefense RDefense
      * Select All   Applicable:      
Shoots Left Right              
      * Select One:                
School Name      
      *    
School Type Prep Public        
      * Select One:        
Club Team Hockey :          
High School Coaches Name and Contact Info:
        High School Coaches Name:   Email Address (if known)
      *  
        Home Phone:   Cell Phone (if known)
         
Club Hockey Team Coaches Name and Contact Info:
        Club Hockey Team Coaches Name:   Email Address (if known)
      *  
        Home Phone:   Cell Phone (if known)
         
Your Information we will pass on to Programs        
      HS Senior? Yes No Please let us know if you
are a High School Senior
 
      * Select One:  
      Permission? Yes No We request your permission to put your
email address in our program for the Scouts		  
      * Select One:  
Programs of Interest:
        Choice #1    
        School Name:    
      *    
        Coaches Name:   Coaches Email (if known)
         
        Choice #2    
        School Name:    
         
        Coaches Name:   Coaches Email (if known)
         
        Choice #3    
        School Name:    
         
        Coaches Name:   Coaches Email (if known)
         
      * SAT  Math  Reading Writing          
    Enter Scores:      
      * ACT                
      *  GPA                
Extra Info or any Information to pass on to Programs    
         
           
        Waiver and release:  
       

I acknowledge that the sport of hockey has inherit risks of injury. In consideration of enrolling in a program of instruction with Durham Hockey Institute, the undersigned hereby:

1. Releases and discharges Durham Hockey Institute, it’s directors, employees and agents (the “Releasees”) from any and all liability for any injury however occurring, whether from negligence on the part of the Releasees or otherwise: and
2. I hereby agree to indemnify and save harmless the Releasees from any and all causes of action brought against them as a result of any injury however occurring.

  
    Please select the box
indicating if you have read, understood and accepted the
Waiver and Release		      
           
      *     <<< Please Check
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