AJAX-PICKERING -
SUMMER 2017 3 on 3
HOCKEY TEAM ENTRY
Team Name: ________________________________________________________________________________________
Team Colours: (team
provides sweaters) __________________________________
Division (Tyke, Novice, Atom, Peewee, Bantam, Midget) )___________________________________
Team Rep Name________________________________________
Team
Rep.Address:________________________________________________________________________________
City________________Postal Code__________
Home Phone:___________________________ Bus: ___________________________
E-mail:_________________________________________________________
(for standings/newsletters/schedule changes etc)
TEAM REP HEALTH CERTIFICATION: Upon signing
this application, the team rep certifies that all players are in good normal health, are properly equipped (full hockey
equipment mandatory) and have no abnormal handicaps.
PLAYER/PARENT/GUARDIAN
CONDUCT: The Ajax Summer Minor Hockey League and/or 771227 Ontario Ltd. operates on Municipal property with the permission
of the Town of Ajax. To this end, players, parents/guardians and participants will respect the facilities and grounds and
will abide by the rules set forth by the facility and staff.
TEAM
REP WAIVER AND INFORMED CONSENT: To whom it may concern: I, the undersigned, authorize The Ajax Summer Minor Hockey League
and/or 771227 Ontario Ltd. and/or Town of Ajax and/or anyone acting on their behalf to acquire necessary medical aid that
may be required as a result of any accident or injury which may be sustained by members of this team. I have been warned and
informed via this document that insurance coverage is not provided and there are serious physical risks associated with hockey,
including, but not limited to falls and/or collisions with stationary objects, other players, skates pucks and sticks. My
signature below indicates my confirmation that I have explained these risks to the parents of all team member. And I
hereby indemnify and save harmless the The Ajax Summer Minor Hockey League and/or 771227 Ontario Ltd. and/or Town of Ajax
and/or anyone acting on their behalf from any and all actions, claims and demands for damages, loss or injury however arising
which here to after may have been sustained by any member of the team while participating in any activity or facility operated
by The Ajax Summer Minor Hockey League and/or 771227 Ontario Ltd. and/or Town of Ajax. My signature below indicates that I
am the team rep having the legal right to assume the conditions above on behalf of the team players named on the roster sheet.
My signature below also indicates that I have thoroughly read and agree to all of the terms above.
TEAM REP SIGNATURE
________________________
DATED THIS ________DAY OF ________, 2017
NOT VALID
WITHOUT ROSTER SHEET INCLUDING SIGNATURES AND PAYMENT
TEAM ENTRY FEES: $2790.00 ($2389.39 & $310.61 = $2790.00)
MAIL
TO: AJAX PICKERING 3 ON 3 SUMMER HOCKEY, 23 Divine Dr, Whitby, ON L1R 2T4
No in-person deliveries - no refunds
