player registration form

PLAYER REGISTRATION FORM
Name:
___________________________________________________________________________________
(Last Name)
(Middle Initial)
(First Name)
Address: ___________________________________________________________________________________
(Street)
(City)
(Postal Code)
Birth: ____/____/____
DD MM
YR
Player Telephone: Residence _____________________________
Cell# ____________________________
Player Email Address: _________________________________________________________________
Parent(s) or Guardian name(s) ( UNDER 18) ____________________________________________
Parent e-mail: __________________________
Parent e-mail: _________________________________
Parent Telephone: ___________________________
Health Card # ___________________________
st
nd
Position 1 Pref: ___________ 2
Pref: ____________
Team Played With Last Year: ___________________________________________________________________
Height: ________ Weight: _________ Shot: Left ______ Right ______
Do you work: No ____ Yes ____ If yes: Full-time ____ Part-time _____
School: ________________________________________ Grade Entering This Year: ____________
RELEASE AND WAIVER
In consideration of acceptance of this registration in the Soo Thunderbirds Camp, I, for myself, my heirs,
executors, administrators and assigns, release the Soo Thunderbirds Hockey Club its respective servants, agents or
employees and all organizers, sponsors, representatives, of the Soo Thunderbirds Training Camp and any other
person or organization assisting in this event from any and all claims, demands, damages, actions or causes of
actions arising out of or in consequence of any loss, injury or damage to my person or property incurred while
attending at or participating in a training camp notwithstanding any such loss, injury or damage that may have arisen
by reason of the negligence of the Soo Thunderbirds Hockey Club or any other party above-mentioned. Without
limiting the generality of the foregoing, I further release any recourse which I may now or hereafter have resulting
from any decision of the Soo Thunderbirds Hockey Club.
I further state that the registrant is in proper condition to participate in this event and I am aware that
participation could in some circumstances, result in physical injury. The registrant is attending this training camp of
his own free will and has obtained permission, from the physician of choice to participate in the training camp.
Permission for the free use of the registrant’s name and picture in broadcasts, telecasts or written accounts
of the events is hereby granted.
Full particulars of any physical condition which may affect the registrant’s health, ability or performance has
been disclosed in writing to the organizers of this event
____________________________________
Signature of Registrant
Date _______________________________
___________________________________________
Signature of Parent or Guardian (If 18 years of age or under)
Date__________________________________________
INDEMNIFICATION
In consideration of the Soo Thunderbirds Hockey Club accepting the written registration, I hereby agree to
indemnity the Soo Thunderbirds Hockey Club its servants, agents and employees and all organizers, sponsors,
representatives of the Soo Thunderbirds Hockey Club arising out of or in consequence of the attendance or
participation of by the above named registrant in the Soo Thunderbirds Training Camp
____________________________________
Signature of Registrant
Date _______________________________
___________________________________________
Signature of Parent or Guardian (If 18 years of age or under)
Date__________________________________________
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I, the undersigned, permit the Soo Thunderbirds and the NOJHL to place my
son’s name, picture, hockey statistics, height, weight, high school and birth
date or any other information, at the Soo Thunderbirds and the NOJHL
discretion, relevant to hockey on the web site (website address
www.tbirdhockey.ca and www.nojhl.com ), in the Individual Team Programs
and to be published in recognized media outlets (i.e. TV, newspaper and
radio) and places which promote hockey associated with the Soo
Thunderbirds and the NOJHL
___________________________
(Players Name Print)
__________________________________
(Parent’s / Guardian’s Name Print & Signature)
______________
Dated
PLAYER MEDICAL FORM
Name: _______________________________________________________________________________
Date of Birth: _____/ _____ /_____
DD
MM
Health Card #
________________________________________
YR
MEDICAL HISTORY
Have you ever had any of the following?
Y N
Arthritis
Chronic Migraines
Epilepsy convulsive
Asthma
Hay Fever or Sinus
Other Allergies
Eye Difficulties
Respiratory Problem
Frequent Bronchitis
Chronic Illness
Y N
Chronic Indigestion
Chronic Headaches
Kidney Stones
Rheumatic Fever
Heart Disease/Murmur
High Blood Pressure
Tuberculosis
Diabetes
Mononucleosis
Kidney Disease
Y N
Enlarged Liver/Spleen
Hernia-Abdom/Inguinal
Tumors/Growths/Cysts
Anxiety Attacks
Frequent Colds
Motion/Car Sickness
Ear/Nose Problems
Throat Problems
Chest Tightness
Jaundice
Y N
Gastrointestinal Issue
Joint Conditions
Bone Condition
Chicken Pox
Scarlett Fever
Pneumonia
Hepatitis
Appendicitis
Shortness of Breath
If YES to any of the above please give details:
_______________________________________________________________
Any other serious illness, hospitalizations, injuries, deformities not listed above
_______________________________________________________________
Do you wear during ___ Glasses ___Contacts ___ Both ___ N/A
athletic participation ___ Yes ___ No
Allergies:
Bee Stings Y N
Iodine or Similar Y N
Aspirin
Sulfa Drugs
Y N
Y N
Grass or Ragweed
Latex Allergies
Y N
Y N
Penicillin
Y N
Anti-Inflammatory Y N
Please list any food or other allergies not mentioned above:
_________________________________________________________________________________________________________
Have you ever suffered from a fracture or dislocation? Please explain.
_________________________________________________________________________________________________________
Any medical conditions which will interfere with athletic participation?
details.
YES
NO
If yes, describe or give
_________________________________________________________________________________________________________
Are you currently on any medications, either prescription or over the counter?
details.
YES
NO, if yes describe or give
_________________________________________________________________________________________________________
Concussion History:
Have you suffered a concussion:
Did you ever have a loss of consciousness due to a concussion
Have you ever been hospitalized for a concussion
YES
YES
YES
NO
NO
NO
If yes, how many ______
If yes, how long ________
If yes, how long ________
Emergency Contact
Name: ___________________________Relationship: ______________________Telephone: __________________
I understand that it is my responsibility to keep the team management advised of any change in the above
information as soon as possible and that in the event no one can be contacted team management will take my child
to the hospital/M.D if deemed necessary.
I hereby authorize the physician and nursing staff to undertake examination, investigation and necessary treatment of
my child. I also authorize release of information to appropriate people (coach, physician etc.) as deemed necessary.
Signature of Parent or Guardian: ___________________________________________ Date __________________________
Required under the age of 18
Participant 18 years or older
: ___________________________________________ Date __________________________
Rink Location: John Rhodes Community Center 260 Elizabeth St Sault Ste Marie, Ontario Canada Hotel Information: Super 8 Hotel 184 Great Northern Rd Hwy 17 North Sault Ste Marie, Ontario Phone: 705‐254‐6441 We are offering our one queen, two queen and one king rooms all for the $75.00 price. All pricing will be flat rate for 1‐4 people in the room. We will offer a junior suite for $85.00 (one king bed in room and Jacuzzi tub in bathroom, and standalone shower unit and large workstation) and we will offer the fireplace suite for $95.00 (one king sized bed, triple sided fireplace, Jacuzzi tub in the main room, stainless steel fridge in room, large separate shower unit, large corner workstation‐‐huge room that spans across the front of the hotel)