Ascend Hockey Clinic Registration

1
Player name
First Name
Last Name
2
Goalie?
YESNO
3
Date of Birth
Date
Year
Month
Day
4
Age
5
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Emergency Contact Name
7
Emergency Contact Phone
Area Code
Phone Number
8
Parent Name
First Name
Last Name
9
Parent Phone
Area Code
Phone Number
10
Parent Email
example@example.com
11
Clinic RegistrationChoose your option.
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ORDER SUMMARY
Total costUSD
YORKTOWN SKILLS SESSION NOVEMBER 18PAYMENT METHODS: Venmo:ascendhockey, paypal:Hockey93, Zelle: pblamoureux@gmail.com or 434-546-4246
$65.00Edit
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$90.00Edit
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CAROLINA ICE ZONE PURE CHECKING CLINIC ( All ages) April 16
$55.00Edit
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CAROLINA ICE ZONE ADULT SKILLS CLINIC ( Beginner -Advanced Group) April 16
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*FULL CAROLINA ICE ZONE PRO SKATING AND SKILLS CLINIC with PURE CHECKING ( Advanced Group) April 15-16
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Total cost $0.00
12
Insurance Provider
13
Policy Number
14
Group Number
15
Policy Holder Name
16
AllergiesPlease List
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Large
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Small
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Ok
17
Medical ConditionsPlease Explain
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Small
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18
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
19
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
20
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
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