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| Check One : Deck/Street
_____ Inline Roller _____ |
Fall 2011- Deck $65 , Roller $70 |
| Participant's Name : _______________________________________________________ Age : ____________ Phone : ______________________________________ Date of Birth : ____________________________ Address : ______________________________________________________Zip Code : _____________ Participant's T - shirt Size ( Deck only): _____________ Email address _____________________________ Allergies / Medical Restrictions : ___________________________________________________________ School District / School : _________________________________________________________________ Parent / Guardian's Name (s) : _____________________________________________________________ |
| EMERGENCY CONTACT :____________________________________ Telephone : _________________ Relationship to child : _______________________________________________________________________ |
| Participant's Equipment Needs : ( complete only if using Starhawks equipment ) *Helmet : Jr. _______ Sr. _______ *Shin Guards : Sm. ______ Med. ______ Lg. ______ ( * Refundable Deposit Required : $15 per helmet , and $5 for each pair of shin guards ) |
| Parent / Guardian Signature : ___________________________________________ Date : _________________ |
| My signature above does hereby for myself, my children, all heirs, successors, and assigns agree to release, waive, and forever discharge from all liabilities; and further to indemnify & hold harmless the Starhawks Youth Hockey Association and Ozzy's Sports Fun Center, And all associated officials, volunteers, and employees from any liability, loss, damage, or costs which may be incurred due to my child's participation in this program. |
Mail completed forms to Starhawks Youth Hockey P.O. Box 15145 Reading, Pa. 19612 with checks payable to STAR