********PLAYER INFORMATION SHEET********
PLAYER NAME__________________________________Birthdate ____/ ____ /____
PARENT’S NAMES ___________________& ____________________
ADDRESS_______________________________________, IL ZIP______________
HOME PHONE ( )_________________PLAYER’S CELL ( )_________________
MOM’S CELL ( )__________________ DAD'S CELL ( )_________________
BEST EMAIL ADDRESS TO
SUPPLY TEAM INFORMATION _____________________________
List here any special or specific information the coaching staff would need to know about your child.______________________________________________________________
_______________________________________________________________________
Release & Hold Harmless Agreement
Please read this form carefully and be aware in registering yourself or your minor child/ward for participation in the above program/programs, you will be waiving and releasing all claims for injuries you or your minor child might sustain arising out of the above program/programs. I recognize and acknowledge that there are certain risks of physical injury to participants in the above program and I agree to assume the full and entire risk of any injuries, damages or loss, regardless of severity, which I or my minor child/ward may sustain as a result of participating in any or all activities connected or associated with such program/programs. I agree to waive and relinquish all claims I or my minor child/ward may have as a result of participating in the program against John Lenzi or Howard Baugher, CCM Hockey Club,Crystal Ice House, Crystal Lake Central High School, and any of the officers, agents, members, servants and/or employees of the mentioned entities. I further agree to indemnify and hold harmless and defend John Lenzi or Howard Baugher, The CCM Hockey Club, Crystal Lake Central High School, and any of the officers, agents, members, servants and/or employees of the mentioned entities from any and all civil claims resulting from injuries damage or losses sustained by me or my minor child/ward arising out of, connected with, or in any way associated with the activities of the program/programs. In the event of any emergency, I authorize John Lenzi or Howard Baugher, The CCM Hockey Club, Crystal Lake Central High School officials to secure from any licensed hospital, physician and/or medical personnel and any treatment deemed necessary for me or my minor child/ward's immediate care and agree that I will be responsible for payment of any and all medical services rendered. I have read and fully understand the above Program Details, Waiver and Release of All Claims and Permission to secure treatment.
BY SIGNING BELOW I AGREE TO THE ABOVE RELEASE AND HOLD HARMLESS AGREEMENT.
___________________________________________________________ DATE _____________________
( PARENTS SIGNATURE )
Last Name: _________________________________________________________
First Name: ____________________________ Nickname: __________________
Date of Birth: _____________________ Height __________ Weight ___________
Parents: ____________________________________________________________
Home Address: ______________________________________________________
City: ________________________________ Zip Code: _____________________
Home Phone: ______________________ Player’s Cell: ______________________
Father’s Cell: ______________________ Mother’s Cell: _____________________
Parent’s E-Mail: ______________________________________________________
Player’s E-Mail: ______________________________________________________
High School ________________________________ Year: Fr So Jr Sr
Position _____________________________ Shoots R L
Jersey Size _______________
Return completed registration form by August 15thwith deposit of $600.00
(or $800 for New players – see enclosed Fee Schedule for details) to:
C.C.M Hockey Club
P.O. Box 1525
Crystal Lake, IL 60039-1525
Please call Rick Ridenour at 815-459-3673 with any questions