Octane_Summer

Information

Name:

*

Street Address:

City:

State/Province:

Zip/Post Cd:

Country:

Telephone:

Cell:

( ) -

Email:

*

Birth Date:

Height:

Weight:

*

MM * DD *YY

* Ft

* In

* lbs

Emergency Contact Information

Name:

Phone or Cell number:

( ) -

League of Play:

Select League:

Position

Goalie

Center

LWing

RWing

LDefense

RDefense

*

Select All Applicable:

Allergies

Yes

No

If yes, please detail allergies in
'Extra Detail Information' below

*

Select One:

Tournament:

*

Select Tournament:

DHI Jersey

Team Information

Team Name

Coaches Name:

Email Address (if known)

*

Home Phone (if known)

Cell Phone (if known)

( ) -

Extra Info

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

*

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Octane Summer Teams