Child’s Name *

What Position Does Your Child Play *

What Level Of Hockey Will Your Child Be Playing This Hockey Year *

Birth Date *

Parent/Guardian Names *

Phone Numbers *

Emergency Contact Name & Number *

Any Allergies or Medical Issues *

AB Health Care Number *

I grant permission to Top Goaltending, Better Life Fitness, Larry Moberg and Jamie Bastien to publish any and all publications for any lawful purpose including, without limitation, publicity, illustration, advertising, and Web content. *

I, THE PARENT/GUARDIAN OF THE ABOVE NAMED PLAYER, HEREBY GIVE MY APPROVAL FOR HIS/HER PARTICIPATION IN THE ABOVE NAMED ACTIVITY DURING THE CURRENT SEASON. I ASSUME ALL RISKS INCIDENTAL TO THE CONDUCT OF THE ACTIVITY AND TRANSPORTATION TO AND FROM THE ACTIVITIES. I DO HEREBY RELEASE, ABSOLVE AND HOLD HARMLESS THE ORGANIZERS OF THE ACTIVITY, SPONSORS, SUPERVISORS, AND ANYONE CONNECTED WITH THE PROGRAM. IN CASE OF INJURY TO THE ABOVE NAMED CHILD, I HEREBY WAIVE ALL CLAIMS AGAINST THE ORGANIZERS AND SUPERVISORS OF THE ACTIVITY. *

Today's Date *