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Power Hockey Development Inc.

The Hockey Training Company

Registration Form

PRINT HERE (right click & select print)

Fax to 416-636-8772

Pay Online using Credit Card - see PHD Web Store tab

Mail Application to:

12 Lismer Cres.

Bolton, ON L7E 2L9

Please Circle to select desired Program Below:

Prospects or CHG Summer League

PERSONAL INFORMATION

PLAYER'S NAME:_______________________________________________

ADDRESS: __________________________________________APT: _______

CITY:________________________________PROV/ST:______________________

POSTAL/ZIP: ______________ BIRTH DATE: _____________________AGE: _______

TEL(H): ____________________TEL(W): __________________

EMAIL: _________________________________________________

HEALTH CARD #: ___________________________________


HOCKEY INFORMATION

Past Season/Current Team: _____________________________ Position ____________

Stats (Goals/Asst/Pts) _________________________ School/Grade:______________________

OHL Rights __________________ Year Selected in OHL Draft ___________

Agent/Advisor _____________________________________

Have you written your SAT's: YES or NO SAT Score: __________

GRADE Average: ___________


Release of Liability & Waiver Agreement:

I give my approval to my childs participation in Power Hockey Development activities and agree that Power Hockey Development, its proprietors and employees will not be responsible for any accident or loss however caused and agree to release the proprietors from all claims and damages which may arise as a result of such accidents or loss. In the event of inability to contact me, I hereby give you permission to seek out any necessary medical assistance my child requires while attending your program. In signing the application, I hereby acknowledge that I have read and understand the conditions and certify that the applicant is in good physical and mental health.

Parent's/Guardian's Name: _______________________

Parent's/Guardian's Signature: ____________________

Date:

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