CMS Supersonic Danglers Hockey Camp Registration

2017 Summer Frozen Four CMS Supersonic Danglers Hockey Camp Registration Plymouth State University, Plymouth NH - July 23 - 28 Cardigan Mountain School Player Information Name: ______Date of birth: ______Email: ______Cellular Phone: ______Position: Forward: ____ Defense: ____ Goal: ____ Shoot / Catch: Right: ____ Left: ____ Current Team: ______Jersey Number: ______T-shirt size: Youth XL /Adult S: ____ Adult M: ____ Adult L: ____ Adult XL: ____ Jersey size: Adult S: ____ Adult M: ____ Adult L: ____ Adult XL: ____ Goalie Cut: ____ Shorts size: Youth XL / Adult S: ____ Adult M: ____ Adult L: Dormitory Room: 2 players per room with 2 dormitory beds including bed linens, towel, and blanket Roommate request: ______Parent / Guardian Information Parent’s Name: ______Street: ______City: ______State: ______Zip: ______Phone: (H) ______(W) ______(C) ______Email: ______Parent’s Name: ______

1 Street: ______(Indicate same as above unless different) City: ______State: ______Zip: ______Phone: (H) ______(W) ______(C) ______Alternate Emergency Contact Information Name: ______Relationship: ______Emergency Numbers: ______Will Parent(s) Attend Camp? Yes: ____ No: ____ Will parents require a hotel room? Yes: ____ No: ____ If parents are not attending camp, will player need to be picked up at Airport? Yes: ____ No: ____ Specify Desired Airport: Manchester, NH: ____ Burlington, VT: ____ ACCEPTANCE OF SIGNATURE REQUIRED BELOW LIMITATION OF LIABILITY: My signature indicates that I give my specific consent for my son to participate in all camp related activities. I understand that there are risks of bodily injury that might be involved in these and other activities during enrollment. Further, I agree to release and indemnify, that is, to hold harmless in all respects, the owner, staff and other employees with regard to any claims for injuries that may be incurred as a result of participation in said activities. PLEASE COMPLETE THE CONSENT TO TREAT FORM BELOW

CANCELLATION/REFUND POLICY: No refund of camp tuition after May 15, 2017; deposit is non-refundable

FINANCIAL RESPONSIBILITY: Your signature on this Contract indicates your acceptance of all financial responsibility for fees as well as compliance with the attached policies. Your signature below indicates that you have read and understand our cancellation/refund policy.

PAYMENT: Players are not considered enrolled until the required deposit, sent with this completed contract, has been collected. The deposit is non-refundable.

ACCEPTED ACCORDING TO THE ABOVE TERMS AND CONDITIONS Signature of Parents or Guardians (Required)

Name: ______Signature: ______Date______

PHOTO CONSENT (optional but recommended): I hereby further consent to and authorize the rights to publish, reproduce and use photographs or video of camp participants ONLY on d1hockey.com

2 Name: ______Signature: ______Date______

Name: ______Signature: ______Date______

Camp Tuition: $775.00 if paid by check or $799.00 if paid by credit card. =

Enclose non-refundable $275.00 deposit. Make checks payable to: Mark Damico Write “Supersonic Danglers 2017 Camp” in check memo line For Credit Card Payment visit: http://www.d1hockeyprospects.com/2017ssdinvite.shtml Mail SIGNED registration forms and deposit to: Supersonic Danglers c/o Mark Damico 420 Snipe Ireland Road Richmond, VT 05477

CONSENT TO TREAT – CMS Supersonic Danglers Hockey Camp

TM This is to certify that on this date, I ______, as parent or guardian of ______, give my consent to the Supersonic Danglers Hockey

Camp and its representatives, to obtain medical care from any licensed physician, hospital, or clinic for the above-mentioned athlete, for any injury that could arise from participation in

Supersonic Danglers Camp events. If said athlete is covered by an insurance company, please complete the following:

Name of Insurance Company: ______

Address: ______

Policy Number: ______

Parent/Guardian Name: ______

Parent/Guardian Signature: ______Date: ______

MEDICAL HISTORY FORM Has the athlete had (or presently have) any of the following? ____ Head injury (concussion, skull fracture) ____ Fainting spells ____ Convulsions/epilepsy ____ Neck or back injury ____ Asthma 3 ____ High blood pressure ____ Kidney problems ____ Hernia ____ Diabetes ____ Heart murmur ____ Allergies - specify: ______Injuries to: Shoulder, Knee, Ankle, Fingers, Arm, Other: ______Impaired Vision ____ Contact Lenses ____ Impaired Hearing

Other: ______

______

Have you had a recent tetanus booster? No: ____ Yes: ____ Date: ______

Are you currently taking any medications? No: ____ Yes: ____ Specify: ______

Reason: ______

Has your physician placed any restrictions on your activity? No: ____ Yes: ____

If the answer to any of these questions is or was yes, please describe the problem and its implications for proper first aid treatment below.

Parent/Guardian Signature: ______

Date: ______

CONSENT TO PARTICIPATE IN WATER RELATED ACTIVITIES Swimming activities are scheduled on certain days. All swimming will be closely supervised; players may NOT swim at any time unless accompanied by a staff member. In order for your son 4 to participate in swimming activities, your permission is required. Please check off one of the following:

____ YES, my son may participate in all supervised water related activities during the hockey camp

____ NO my son may NOT participate in any water related activities during the hockey camp

Is there anything else we should be aware of that will help your son to benefit the most from his participation in the CMS Supersonic Danglers camp?

Parent/Guardian Signature: ______

Date: ______