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REGISTRATION
Fields marked with an asterisk (*) are required.
FIRST NAME: *
LAST NAME: *
ADDRESS: *

CITY: *

POSTAL CODE: *

HOME PHONE (XXX-XXX-XXXX): *

BUSINESS PHONE (XXX-XXX-XXXX): *


AGE: *
BIRTH DATE (DD/MM/YYYY): *
EMAIL ADDRESS: *
SEX: * Female Male
HEALTH CARD NUMBER:
MEDICAL INFORMATION:
PARENT NAME: *
SELECT PROGRAM REQUESTED: *
Age Groups • X1: 5-7 • X2: 8-10 • X3: 11-14
Prices listed per person / per week, unless otherwise stated.
SELECT WEEK REQUESTED: *

PAYMENT:
A $50 deposit is required with a post dated cheque for the balance dated for July 1, 2011. A $50 administration fee will be charged for cancellations made after June 1, 2011. Please make cheque or money order payable to:


Xcelerate Hockey, P.O. Box 502, Belmont, ON N0L 1B0

LIABILITY WAIVER:
By clicking on the "Submit" button, I acknowledge, personally and on behalf of my child, heirs and any of his/her/my legal representatives, that the Xcelerate Hockey School, its agents, officials, employees and representatives, shall not be held liable for any death, injury, loss, damage, cost, or expenses arising from participation in any activity directly or indirectly associated with the Xcelerate Hockey School occurring on or off the ice. My child has permission to participate in Xcelerate Hockey School and I give Xcelerate Hockey School permission to render medical attention to my child should it be necessary.

GOALIES

Goaltenders are welcome and will
have specific goalie instruction during
on-ice skills sessions.

Please Register in the appropriate area
of our registration form. Each
goaltender must have his or her
own equipment.

X-2 8 Spaces Available
X-3 8 Spaces Available
$200.00
$135.00*
$320.00*
$320.00


*sibling discount 15% off additional family members in the X-2 & X-3 programs
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