ELEMENTARY/MIDDLE SCHOOL AGED COMMUNITY HOCKEY REGISTRATION FORM
The main goal of our program is to make hockey a fun, safe, and inclusive sport for all who want to play, regardless of age or ability. However, the Community Hockey League does not allow players to play both minor and community hockey.
This form is to be completed on behalf of a student (male or female) who wishes to participate in Community Hockey and returned to your child’s school with payment by Monday, October 1st, 2012. Cash and or cheque will be accepted. *For this year only (until the organization gets a new name) you may write the cheque to your son or daughter’s school and the school will send all monies collected to the community organization.
The fee for this year will be 50.00 per child or a 90.00 family fee (if you have two or more children enrolled in community hockey)
STUDENT NAME ___________________________________________AGE/ GRADE_____________________
HOME ADDRESS_______________________________________________________ POSTAL CODE _________________
HOME PHONE # _____________________________________________MEDICARE CARD NO. _______________________
PARENT/ GUARDIAN __________________________________________________ WORK PHONE # __________________
STUDENT’S PHYSICIAN ________________________________________________PHONE # ________________________
EMERGENCY CONTACT NAME _________________________________________ PHONE # ________________________
ACCIDENT INSURANCE: YES NO ( Please circle one. )
INSURANCE COMPANY:_________________________________________________
POLICY#:________________________________________________________________
MEDICAL INFORMATION NOTE: An annual medical examination is recommended.
1. Date of last complete medical examination ________________________________________________________________________________________________________
2. Date of last tetanus immunization: ________________________________________________________________________________________________________
3. Is your son/daughter/ward allergic to any drugs, foods or medication/other? Yes ________ No________ If yes, provide details:
__________________________________________________________
4. Does your son/daughter/ward take any prescription drugs? Yes ________ No ________ If yes, provide details:
___________________________________________________________________
5. What medication(s) if any should the participant have on hand during the sport activity?______________________________________________________________________________________________
Who should administer the medication? ____________________________
6. Does your son/daughter/ward wear a medical alert bracelet ________, neck chain ________ or carry a medical-alert card? Yes ________ No ________
If yes, please specify what is written on it: ________________________________________________________________________________________________________
7. Does your son/daughter/ward wear eyeglasses? Yes ________ No ________ contact lenses? Yes ________ No ________
8. Please indicate if your son/daughter/ward has been subject to any of the following and provide pertinent details:
epilepsy, diabetes, orthopedic problems, deaf, hard of hearing, asthma, allergies _______________________________________________________________________________________________
head or back conditions or injuries (in the past two years)___________________________________________________________________________________________________
arthritis or rheumatism, chronic nosebleeds; dizziness; fainting; headaches; hernia; swollen or hyper mobile joints, trick or lock knee: _____________________________________________________________
Any other medical information that will limit participation? ________________________________________________________________________________________________________
*Should your son/daughter/ward sustain an injury or contact an illness requiring medical attention during the hockey season, please notify the coach or person responsible for the team.
Equipment- The following is a list of equipment that your son or daughter will require before they are permitted on the ice: Helmet, Neck Guard, Shoulder Pads, Mouth Guard, Elbow Pads, Gloves, Shin, Guards & Socks, Pants, Jock Strap or Jockey Shorts, Skates, Hockey Stick ,Water Bottle (long spout) - to prevent taking the helmet off, hockey tape.
MEDICAL SERVICES AUTHORIZATION
In case of emergency medical or hospital services being required by the above listed participant, and with the understanding that every reasonable effort will be made by the coach or hospital to contact me, my signature on this form authorizes medical personnel and/or hospital to administer medical and/or surgical services including anesthesia and drugs. I understand that any cost will be my responsibility.
SIGNATURE OF PARENT/GUARDIAN ______________________________________________________________ DATE: ______________________
STUDENT ACCIDENT INSURANCE NOTICE-
The Community hockey organization does not provide any accidental death, disability, dismemberment/medical/dental expenses insurance on behalf of the students participating in the activity. For coverage of injuries, you are encouraged to consider your own personal Accident Insurance Plan.
ELEMENTS OF RISK NOTICE-
The risk of injury exists in every athletic activity. Falls, collisions and other incidents may occur and cause injury. Due to the very nature of some activities, injuries may range from minor sprains and strains to more
serious injuries affecting the head, neck or back. Some injuries can lead to paralysis or prove to be life-threatening. These injuries result from the nature of the activity and can occur without fault on either the part of
the student, the coaches or agents or the facility where the activity is taking place. Activities that are identified as having the potential for more serious consequences are Alpine skiing, snowboarding, broomball, cheerleading (acrobatic), field hockey, field lacrosse, gymnastics, and ice hockey. By choosing to participate in this activity, you are assuming the risk of an injury occurring. The chances of an injury occurring can be reduced by carefully following instructions at all times while engaged in the activity.
The Community School Hockey organization attempts to manage as effectively as possible the risk involved for students while participating in this all inclusive hockey opportunity.
ACKNOWLEDGMENT OF RISKS/REQUEST TO PARTICIPATE/INFORMED CONSENT AGREEMENT
I/We have read and understand the notices of accident insurance, and elements of risk.
I/We hereby acknowledge and accept the risk inherent in the requested activity and assume responsibility for my son/daughter for personal health, medical, dental and accident insurance coverages.
I/We request my son/daughter/ward to participate on the Community Hockey team during the 2012-2013 season.
I/We agree that Community Hockey league servants or agents shall not be liable for any injury to my son/daughter/ward or loss or damage to personal property arising from, or in any way resulting
from participation in the above listed activities.
Signature of Parent/Guardian ______________________________________________Date _____________
PLEASE NOTE:
The information provided on this form will be treated confidentially. In keeping with the principles of the Protection of Personal Information Act, it will be used in relation to the provision of medical assistance to the named student, as appropriate. `
Please be advised this is a registration form for a Community Hockey League that was formed to enable all children to be able to have the opportunity to play hockey in a fun, inexpensive and organized manner. It is in no way affiliated with the school your child attends and or with Anglophone South School District.
Thank you- Coaches or persons responsible for the team will be contacting you shortly. When your child(ren) has(have) been placed on a team.
Victoria Moseley
Principal
Saint Rose School
Anglophone South School District
(506) 658-5364