CUMBERLAND GRADS HOCKEY FACTORY

2009 CONDITIONING CAMP APPLICATION FORM

(To be returned prior to July 1, 2009 with $170 payment to CUMBERLAND GRADS)

1329 Colonial Road
Navan, Ontario, K4B 1N1
Telephone (613) 835-4297
Fax (613) 835-3283

Player’s Name: _________________________________________________________________________________

Address: _________________________________________________________________________________

City/Town: ________________________________________ Postal Code: ____________________

Home Tel. No.: (_____) ______________ Emergency Tel. No.: (_____) _______________________

Birth Date:     Day: ________Month: ______Year: ________  Age as of 2009-08-21: ____________

Position: ________                  Height: ______ft ______in                 Weight: ________lbs

2008-09 Team: ________________________________________________________________________________

Coach’s Name: ________________________________   Tel. No.: (_____) ___________________

Family Doctor: _______________________   OHIP Number: ______________________________

Address:         _____________________________    Tel. No.: (_____) ______________________

                     __________________________________

                     __________________________________

Medical History: ________________________________________________________________________________

 ________________________________________________________________________________

Do you:      Wear Eye Glasses:     _____ Yes     _____ No

                   Take Medication:        _____ Yes     _____ No

                    If yes, specify ________________________________________________________________________________

                   Needs braces or special taping to compete:     _____ Yes     _____ No

                   If yes, specify ________________________________________________________________________________

                   _________________________________________________________________________________

The above APPLICANT agrees to save harmless the owners and staff of the CUMBERLAND GRADS JUNIOR “A” HOCKEY CLUB and SOO-BOY SPORTS & ENTERTAINMENT INC. from any recourse for damages or loss which may occur and hereby releases the CUMBERLAND GRADS JUNIOR “A” HOCKEY CLUB and SOO-BOY SPORTS & ENTERTAINMENT INC. from any actions which occur while attending this CONDITIONING CAMP. This release covers traveling to and from the ARENA as well as activities on and off the ice.

Player’s Signature: ________________________________________________

Parent/Guardian’s Signature: ________________________________________

Date Application Returned: ____________________________