Name: _________________________________   Age:_______      DOB: ______________

Height: __________ Weight: __________ Shoots: (Right / Left) Position: _______________

Street:___________________________________________________________________

City: ________________________________________State: ______ Zip: _____________

Home Phone: ________________________ Work Phone:__________________________

E-mail: __________________________________ Paid: (Cash /Check) $______________

Jersey Size: ____________    T-shirt Size: _____________       Waist size: _____________

Emergency Contact Name: ___________________________ Phone: _________________

Student’s Medical History:____________________________________________________

________________________________________________________________________

________________________________________________________________________

WAIVER CLAIM: Acknowledgment that ice and roller hockey are contact sports, I agree that Phillips Hockey, Achieve Goaltending, its agents, servants and employees shall not be liable to be for any injury or damage resulting directly or indirectly from my participation in ice or inline skating and ice or inline hockey, whether incurred on the ice or otherwise in or about the buildings. I further agree that I discharge Phillips Hockey, its agents, servants and employees from all actions, claims, and demands I may have for any injury or damage. I understand that my said agreements, release and discharge shall bind by heirs, legal representatives and assigns and shall insure to the benefit to Phillips Hockey, does not and shall not be considered to guarantee/warrant such equipment as may be used in the conducting of said programs. I also give my consent to Phillips Hockey to treat my son/daughter at their discretion, in case of any emergency incident that may arise throughout the instruction period. Phillips Hockey, reserves the right to use any pictures and video taken during the program for research, instruction and/or advertising purpose.

Parent or Guardian Signature: ____________________________________Date __________