BORGGAARD HOCKEY SCHOOL APPLICATION

To apply, fill out application, sign waiver and make check out to  :

Andrew H. Borggaard

104 Oxford Road

Charlton, MA 01507       

Camp Location & Sessions:  

please circle clinic session   February vacation clinic

                                      Session A  9-10am  /  Session B 10-11am

                                    Summer session

***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___________

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