EIC "Youth Co-ed Floor Hockey" Program

Online Registration Form

www.jotform.com/build/220355618640251

"Youth Co-ed Floor Hockey"

(Ages: 7 to 12)

Activities Every 2nd Sunday (5:00pm - 7:00pm)

April	-	-	17	-	-
May	01	-	15	-	29
June	05	12	19	26	-

$10.50 Per 2 Hour Session (Pre-Registration Required)

or enroll for the Entire Season (8 Sessions)

For Only $84.00 (GST Included)

* STICKS, BALLS, and GOALIE EQUIPMENT SUPPLIED - ON LOAN DURING ACTIVITY *

Edmonton Intercultural Centre (EIC)

9538 107th Avenue NW,

Edmonton, Alberta T5H 0T7

Payment and Registration Notes:

If you are wanting to register more then one athlete/participant for the EIC "Youth Co-ed Floor Hockey" Program, you are required to complete and submit a separate registration form for each participant. Payments can be made by e-transfer to: edmontoninterculturalcentre@gmail.com Please indicate in the comment area of your e-Transfer both the participants name and the total number of sessions you are paying for.

Select Participation Dates*

ALL 8 Sessions ($84.00)April 17 ($10.50)May 01 ($10.50)May 15 ($10.50)May 29 ($10.50)June 05 ($10.50)June 12 ($10.50)June 19 ($10.50)June 26 ($10.50)

Participant Information

Name*

First NameLast Name

Gender*

Birth Date*

MonthDayYear

Age*

Parent/Guardian Information

Alberta Health Card Number*

Parent/Guardian Names*

First NameLast Name

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Home Phone*

Area CodePhone Number

Mobile Phone*

Area CodePhone Number

Email*

example@example.com

Emergency Contact & Health Insurance Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Emergency Contact Secondary Phone Number

Area CodePhone Number

Parental Permission For Emergency Treatment

In the event of illness or accident, I give my permission for emergency treatment by qualified medical personnel for my child, and I authorize the person in charge to arrange to take my child to the nearest hospital if required: I give consent for the facility to secure any and all necessary emergency medical care for my child.

Release of Liability

Although the safety of all participants during sports activities is of primary concern, indoor sport activities at the Edmonton Intercultural Centre's facilities may cause injuries and/or death. As the Parent/Guardian I expressly assume the risk of injury, death, and/or illness arising from any cause, and agree to waive the right to pursue any claim against the Edmonton Intercultural Centre (EIC) and the persons in charge of supervising this event.

Important Notes/Rules

· Dress appropriately · Proper rubber soled footwear must be worn · Outdoor footwear is NOT permitted in the gym · Outside or personal sticks are NOT permitted · NO food or drink allowed in the gym · Both bahaviour and fair play standards will be enforced to assure the safety and promote fun for all participaints · All participants are required to help pick up, clean up, and return to storage all equipment used during thier gym activities · Program organizers reserve the right to form the teams to ensure the talents of all teams are balanced.

I have read and agree to the above conditions*

YesNo

Confirmation E-mail*

Signature*

After completing this form, please click the "Submit" button below. You will receive a confirmation email soon. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at (780) 756-2655

Date Summitted*