Ascend Hockey Clinic Registration

1
Clinic Location* This field is required.Example, Easton MD, Greenville NC.
2
Player name* This field is required.
First Name
Last Name
3
Goalie?* This field is required.
YESNO
4
Date of Birth* This field is required.
Date
Year
Month
Day
5
Age* This field is required.
6
Parent Name* This field is required.
First Name
Last Name
7
Parent Phone* This field is required.
Area Code
Phone Number
8
Parent Email* This field is required.
example@example.com
9
Medical Conditions* This field is required.Please Explain
Huge
Large
Normal
Small
Ok
Ok
10
Health CertificationI believe, to the best of my knowledge, the above-named player to be in good health, (suffering from no illness and able to participate in all types of athletic activity, which demands physical exertion and stamina), and has not been exposed to any infectious disease. It is understood that, except first-aid treatment, Ascend Hockey Camp/Paul Lamoureux will accept no responsibility or liability for accident or illness incurred by the player during the camp program(s). I hereby give my approval for emergency medical treatment, if required. I also agree to have in place complete and current health insurance for the above-named player during the registered program week(s).
YESNO
11
Photo/Media Release I hereby grant to Ascend Hockey and his legal representatives and assigns, the irrevocable and unrestricted right to use and publish photographs of me or my children, or in which I may be included, for editorial, trade, advertising and any other purpose and in any manner and medium; to alter the same without restriction; and to copyright the same. I hereby release Photographer and his legal representatives and assigns from all claims and liability relating to said photographs.
YESNO
12
Minor Release (If registering someone under the age of 18)In consideration of my engagement as a model, and for other consideration herein acknowledged as received, I hereby grant to Paul Lamoureux and Ascend Hockey, legal representatives and assigns, successors in interest, those for whom Photographer is acting, and those acting with his authority, and permission, the irrevocable and unrestricted right and permission to copyright, in his own name or otherwise, and use, re-use, publish, and re-publish photographic portraits or pictures of me or in which I or my children may be included, in whole or in part, including but not limited to composite or distorted in character or form, without restriction as to changes or alterations, in conjunction with my own or a fictitious name, or reproductions thereof in color or otherwise, made through any medium at his studios or elsewhere, and in any and all media now or hereafter known for illustration, promotion, art, editorial, advertising, trade, or any other purpose whatsoever. I also consent to the use of any printed matter in conjunction therewith. I hereby waive any right that I, or the minor may have to inspect or approve the finished product or products or the advertising copy or printed matter that may be used in connection therewith or the use to which it may be applied. I hereby release, discharge, and agree to save harmless Photographer, his legal representatives or assigns, and all persons acting under his permission or authority or those for whom he is acting, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy. I hereby warrant that I am of full age and have every right to contract for the minor in the above regard. I state further that I have read the above authorization, release, and agreement, prior to its execution, and that I am fully familiar with the contents thereof. This release shall be binding upon Paul Lamoureux and Ascend Hockey, legal representatives, and assigns.
YESNO
Should be Empty: