Fall Hockey Development Camps • Registration Form

Dakota Development Camps 2010
Fall Hockey Development Camps • Registration Form

** Pay on-line with your credit card now! Please note that you do not need to create a PayPal account to submit your credit card info securely.

Applicant Profile:

	**First Name:
	**Last Name:
	**Address1:
	Address2:
	**City:
	**Province:
	**Postal Code:
	**Community Centre:

	**Telephone (home):
	Telephone (work):
	Emergency / Cell:
	**Email:

Participant Profile:

	**Child's First Name:
	**Child's Last Name:
	Age:
	Birth Date: (yyyy-dd-mm)
	Height:
	Weight:		(lbs.)
	**Gender:

	Position:

	Health Insurance #:
	Health Remarks / Special Requests:

	Name of Parent / Guardian:

Program Selection:

	1. Optimal Pre-Tryout Powerskating Camp: $199.00

	2. Optimal Pre-Tryout Powerskating & Hockey Skills Camps: $199.00

	3. Optimal Pre-Tryout Body Contact Camp: $50.00

	4. Optimal Pre-Tryout Powerskating & Hockey Skills Camp (girls only): $125.00

**Parental Consent and Waiver of Responsibility:
I hereby authorize the Dakota Community Centre to take photographs of my child named in this application during camp activities, and to display and otherwise use these photographs without charge solely for the purpose of promotional material in connection with the Dakota Community Centre.

I also understand that injuries can arise by accident from the very nature of Camp activities, and I hereby release and waive all rights to any claim or action against Dakota Community Centre arising from injury, loss or damage to my child or to my child's property except where such injury, loss or damage is caused by the negligence of the Dakota Community Centre.

Provide other comments on special instructions here:

Please contact me as soon as possible regarding this matter.