Grow with the Pros ~ June 17-21, 2013

Players Name: _________________________________ Parents Name: ________________________________ Address: _____________________________________ _____________________________________________ Male: ______ ! Female: ______ (Mark with X) Defense: _______ Forward: _______ Goalie: _______ Complimentary Jersey (Circle Size) Youth S/M Youth L/XL Adult: S M L XL Goalie

Ages 7-15 ~ Germain Arena

Home Phone: _________________________________ Work / Cell: ___________________________________ Email: _______________________________________ Date of Birth: __________________________________ 2012-13 Team: ________________________________ Age: _________________________________________ Coach: _______________________________________

Payment Info: $450 for Player and $375 for Goalies

Registration received after April 30th will incur an additional $50 fee.

Mail form & payment to: Ryan Brindley Hockey Development; 12559 Grandezza Circle, Estero, FL 33928

Equipment Needed All players including goaltenders must provide and properly wear their own fully legal equipment (helmets, pads, sticks, gloves, etc.) The Pro Shop is well stocked to handle most of your needs. Medical Insurance EACH PARTICIPANT MUST HAVE THEIR OWN MEDICAL INSURANCE. Ryan Brindley Hockey Development Camps will not be responsible for any medical or dental insurance or expenses. A medical and liability waiver release statement including vital medical information and emergency contact person is included on this form. It must be completed and signed by a parent or guardian and included with registration. No student may participate without turning in this completed form. Warranty and Consent Warranty and consent (of parent/guardian) Assumption of Risk Release and Waiver of Liability/Indemnity Agreement I understand and agree, on behalf of myself, my minor, my child/ward, my heirs, assigns, personal representatives and next of kin, that my participation and execution of this document constitutes: 1) An unqualied assumption of all risks associated with participation in this program by my minor child/ward or me even if arising from negligence, or gross negligence, including any compounding or aggravation of injuries caused by negligent rescue operations or procedures, of the program organizer and any persons associated therewith or participation therein and 2) 2) A full and nal release and waiver of liability of the program organizer and all persons and organizations associated with it and the program including, without limiting the generality of the foregoing, its ofcers, directors, ofcials, agents, and/or employees, other participants, sponsors, advertisers, owners and/or lessors of the premises used to conduct the program, sanctioning bodies, medical or rescue personnel (the releasees), of and from with respect to all injury, disability, death or loss or damage to person or property whether arising from the negligence, or negligent rescue of or by the foregoing or otherwise, and 3) An understanding not to sue the releasees for any loss, injury, costs of damages of any form or type, however, caused or arising, and whether directly or indirectly from the participation of my minor child/ward in the program. 4) An agreement to indemnify, and to save and hold harmless the releasees, and each of them, from any litigation expense, legal fees, liability, damage, award or cost, of any form or type whatsoever, they may incur due to any claims made against them or any one of them whether the claim is based on the negligence or the gross negligence of the releasees or otherwise. I have read this document thoroughly. I understand that the releasees are relying upon my warranties, assumptions waiver and release, undertakings and agreements when accepting my minor child/ward participation in the program. I understand that by signing this document I give up substantial legal rights I and/or my minor child/ward would otherwise have. I sign this document voluntarily and without inducement. __________________________________________________________! Signature of parent/guardian ! ! ! Date! ! ! __________________________________________ Name of participant (please print) !