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Borggaard
Hockey School Application
To apply, fill out application, sign waiver and send check to:
Andrew H. Borggaard
104 Oxford Road
Charlton, MA 01507
Camp Location & Dates: Worcester
(Buffone Arena)- May 7th-August 22,, 2010
Payments are as follows : $ 240 due at registration
***No refunds will be issued to a player should they leave, miss or are expelled from
the amp***
(Parent/Guardian initials) ________
Player
Information
Name: ________________________________________________________
Parent Name: ________________________________________________________
Address: __________________________________________________________
City: ______________________________State: _____Zip:__________
Age: _____DOB: _____________
Phone: (day) ___________ (evening) _____________ (cell) _________
Email: ____________________________
# Years Hockey Experience: ______Position: ______________
Hockey Organization: ___________________________________
Emergency
contact:
Name: ___________________________ Relation: ________________
Address: ________________________ Phone: __________________
Allergies/Medical Alerts: __________________________________________________
Medical Insurance Carrier: __________________________________________________
Waiver and Agreement:
I agree that the applicant named above is fully covered by health insurance to cover
any personal injury or property damage sustained by the student while participating in any activities or while on the premises
of Borggaard Hockey Schools. I understand that Borggaard Hockey School, the instructors and the skating rink/fields will not
be held responsible for any accidents or loss, however caused, and agrees to release the proprietors and/or skating rink from
all claims or damages which may arise as a result of or any reason of such accident or loss. (Guardian/Parents Initials) ____________
Medical Release:
I acknowledge the applicant is in good health and is able to participate in the physical
activity of this program. In the event my child is injured during absence of parent/guardian, I give my permission for the
person in charge to seek medical attention
if necessary.
Signature
of
Parent/Guardian: ___________________________________Date___________
www.Liveforhockey.com
508-962-0079 | 
