Camper Registration with KPrimeau Jr Viper

Information

Name:

*

Street Address:

City:

State/Province:

Zip/Post Cd:

Country:

Telephone:

Cell:

( ) -

( ) -

Email:

*

Birth Date:

Height:

Weight:

*

MM 00 01 02 03 04 05 06 07 08 09 10 11 12  * DD 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  *YY 0000 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

* 0 3 4 5 6 7 Ft

* 0 0 1 2 3 4 5 6 7 8 9 10 11 In

* lbs

Emergency Contact Information

Name:

Phone or Cell number:

Position

Goalie

Forward

Defense

*

Select One:

Shoots

Left

Right

*

Select One:

Allergies

Yes

No

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

*

Select One:

Resident

Yes

No

If attending an Oshawa Summer Camp, please indicate if you will be a resident (lodger) at the camp, otherwise check 'N'

*

Select One:

Jersey Size:

Select Youth Size:

None Selected Small Medium Large Extra Large

or

Select Adult Size:

None Selected Small Medium Large XLarge XXLarge

Camp of Interest:

*

Select Camp:

None Selected Atlantic City Mites (2000-2001) Atlantic City Squirts (1998-1999) Atlantic City Peewees (1996-1997) Atlantic City Bantams (1994-1995) Ayton Camp 2000-2001 Birth Years Ayton Camp 1998-1999 Birth Years Ayton Camp 1995-1997 Birth Years March Break 1999-2001 Birth Years March Break 1996-1998 Birth Years Oshawa Goalie Summer Camp Week 1 Resident Oshawa Goalie Summer Camp Week 1 Commuter Oshawa Summer Camp Week 1 Mites/Novices (2000-2001) Resident Oshawa Summer Camp Week 1 Mites/Novices (2000-2001) Commuter Oshawa Summer Camp Week 1 Squirts/Atoms (1998-1999) Resident Oshawa Summer Camp Week 1 Squirts/Atoms (1998-1999) Commuter Oshawa Summer Camp Week 1 Peewees (1996-1997) Resident Oshawa Summer Camp Week 1 Peewees (1996-1997) Commuter Oshawa Summer Camp Week 2 Peewees (1996-1997) Resident Oshawa Summer Camp Week 2 Peewees (1996-1997) Commuter Oshawa Summer Camp Week 2 Bantams (1994-1995) Resident Oshawa Summer Camp Week 2 Bantams (1994-1995) Commuter Oshawa Summer Camp Week 2 Midgets (1992-1993) Resident Oshawa Summer Camp Week 2 Midgets (1992-1993) Commuter

League of Play:

Select League:

None Selected AE A AA AAA Other (Detail Below)

Where did you hear about us?

Friend

Brochure

Internet

EastCoast

Other

Select One:

Referrers Name & Email Address:

Name:

Email Address (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

*

<<< Please Check <<< Waiver Box

 

*  Asterisk items are required fields

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