:: Xcelerate Hockey ::

Full Day Programs
First Class Facilities
15 Hours of Ice Time per Session
Low Student-Instructor Ratio
Friday Lunch Provided
Professional, College and Junior Hockey Instructors
Each Student Receives a Hockey Jersey
Weekly Mystery Guest
Snacks Provided

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FIRST NAME: *

LAST NAME: *

ADDRESS: *

CITY: *

POSTAL CODE: *

HOME PHONE (XXX-XXX-XXXX): *

BUSINESS PHONE (XXX-XXX-XXXX): *

2009/2010 TEAM ASSOCIATION:

PLAYER POSITION: *

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, 2010. A $30 administration fee will be charged for cancellations made after June 1, 2010. Please make cheque or money order payable to:

Xcelerate Hockey
P.O. Box 502 Belmont, Ontario 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.

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