Grand Rapids Hockey Camp - 2009 Registration Form

Week One July 19-24 (Sunday night through Friday evening)	Rates	Week Two July 26-31 (Sunday night through Friday evening)

_______ Squirts		_______ PeeWees
_______ PeeWees		_______ Bantams

_______ Resident	_______ Day Camper	_______Check here if you are a goalie
Name _________________________________________________________
Address _______________________________________________________
______________________________________________________________
Birth Date _____ / _____ / ______
Parents / Guardians ______________________________________________
Phone: Day_____________ Night____________ Emergency____________
Email Address __________________________________________________

Please Note: This form, as well as the Medical History Form and the Consent To Treat Form, must ALL be printed out, completed, and sent into the address below.

All applications must include a $300.00 deposit, refundable only with medical verification. Must be prior to May 31, 2009.

Parent release and indemnity agreement:
To the IRA Civic Center Summer Hockey School: I/We hereby release the City of Grand Rapids, its employees, and the Grand Rapids Hockey Camps instructors from all claims on account of any injuries which may be sustained by my/our child while participating in activities at the IRA Civic Center. I/We agree to indemnify the City of Grand Rapids, its employees, and the Grand Rapids Hockey Camps instructors for each claim which may hereafter be presented by my/our child as a result of injury. I/We also certify that my/our child is medically fit to participate in the Grand Rapids Hockey Camps program.

Parent Signature _______________________________________________
Date ____ /____ /_______
Mail to:
IRA Civic Center
420 N. Pokegama Ave.
Grand Rapids, Minnesota
55744

For More Information:
Contact Dale Anderson or Sara Holum at 218.326.2500