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:
_________________________________________________
Payments are as follows (please X)
_____
Non-refundable 50% deposit (remaining 50% upon first day)
______
Payment in full (50% non- refundable)
****No
refunds will be issued to a player should they leave, miss or are expelled from the camp** (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
