Len Chittle's Hockey Academy Applications Form

Player's Name:       Gender:  Male  or   Female

Street: 

City:       Postal Code: 

Mothers Name:       Fathers Name: 

Email: 

Telephone 1:       Telephone 2: 

Age at Camp:       Date of Birth:      

Sweater Size:     Youth - Small / Medium  Large / X-Large     

                            Adult - Small Medium  Large  X-Large

Allergies / Medical Info: 

Sessions

March Break Sessions: 

Pre-Tryout Sessions: 

Summer Sessions: 

Waiver and Consent

I, the undersigned parent or guardian, herby waive, release and discharge any and all claims for death, personal injury, property damage or loss of personal property which may accrue as a result of participation in this program.  I herby acknowledge, the risks of bodily injury and or property damage inherent in participating in hockey / skating clinics, practices, and games.  I herby give consent for my child to participate in Len Chittle's Hockey Academy and certify that I have read, understood, and agree to be bound by the foregoing provisions.

Date:        Printed Name:      

                            Signature of Parent/ Legal Guardian:  _______________________

Call Len/Janine Before Mailing

(905) 939-7962 (Home) or (416) 653-3180 Ext. 330    

Please mail completed application and cheque to:

Len Chittle

21 Weedon Crt.  Kettleby, ON  L0G 1J0

Print This Page