RegistrationForm

Registration No. _____________

South Coast Special Needs Kids

HOCKEY REGISTRATION 2009

Before October 10th mail to:

Diane Vrooman

46 Berkley Crescent

Simcoe, Ont. N3Y 2K5

Player’s Name ____________________________________________

Parent/Guardian Name _____________________________________

Player’s Address

________________________________________

(street address)

_____________________ _________________

(town)

(postal code)

__________________

_________________

(phone #)

e-mail address

Birth Date

_________________ Health Card # _____________________

Doctor’s Name _______________________ Phone # _____________

Player’s special need ________________________________________

Parental Consent to Play Hockey

I, the undersigned parent or legal guardian of ______________________ do hereby consent and agree that the above-mentioned player may participate with the South Coast Special Needs Kids sports group. I hereby waive and release any and all right and claim for damages and/or liability I may have against the above organizers and any associations connected with them for any and all injuries suffered by the above named player while participating with this group. It is further agreed that this consent shall remain in full force until such time as it is cancelled in writing by the undersigned.

_____________________________________

_______________

(Signature of parent or legal guardian) (date)