registration@hockeyskillsacceleration.com
HOCKEY SKILLS ACCELERATION APPLICATION
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Mail your application with your payment to:
HSA
P.O. Box 35792
Brighton, MA. 02135-0014
Name: | _______________ | ___________________ | Date:____________ | _________________ |
Address: | _______________ | City:_______________ | State:___________ | Zip:______________ |
Phone: | _______________ | Emergency Phone:____________ | Position:_________ | Date of Birth:____________ |
Program Code: | _______________ | ___________________ | _________ | _________________ |
E-Mail: | _______________ | ___________________ | __________________ | _________________ |
WAIVER: I THE UNDERSIGNED DO HEREBY WAIVE ALL CLAIMS AGAINST THE HSA, PILGRIM ARENA, MDC, IORIO ARENA, DEXTER SCHOOL OR ANYONE ASSOCIATED WITH THESE INSTITUTIONS. I WILL ASSUME ANY RESPONSIBILITY FOR ACCIDENTS AND MEDICAL OR DENTAL EXPENSES INCURRED AS A RESULT OF PARTICIPATION IN THE HSA PROGRAM.
FURTHER I RECOGNIZE THAT MY SON/DAUGHTER MUST WEAR USA HOCKEY APPROVED SAETY EQUIPMENT INCLUDING A MOUTH PIECE.
THE APPLICANT IS IN GOOD HEALTH AND ABLE TO PARTICIPATE IN THE PHYSICAL ACTIVITY OF A VIGOROUS PROGRAM THAT MAY INCLUDE PHYSICAL CONTACT.
FURTHER I RECOGNIZE THAT MY SON/DAUGHTER MUST WEAR USA HOCKEY APPROVED SAETY EQUIPMENT INCLUDING A MOUTH PIECE.
THE APPLICANT IS IN GOOD HEALTH AND ABLE TO PARTICIPATE IN THE PHYSICAL ACTIVITY OF A VIGOROUS PROGRAM THAT MAY INCLUDE PHYSICAL CONTACT.
Signature:________________________________________ [PARENT/LEGAL GUARDIAN] | Date:_____________ |
50% DEPOSIT IS REQUIRED,
Balance is DUE 2 WEEKS PRIOR TO PROGRAM START
Make Money Orders payable to HSA
Balance is DUE 2 WEEKS PRIOR TO PROGRAM START
Make Money Orders payable to HSA
Mail your application to;
HSA
P.O. Box 35792
Brighton, MA. 02135-0014
