2006 Offensive/Defensive Registration Name Date of Birth mm 01 02 03 04 05 06 07 08 09 10 11 12 dd 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 yyyy 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Parent's Name Phone () - Street City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Height ft 4 5 6 in 0 1 2 3 4 5 6 7 8 9 10 11 Weight Email address Years Skating Last lever played for Mites Squirts Pee Wees Bantam Midget AAA AA A B C Session Code NAN1 NAN2 NA3 NM4-AD NAS5-AD MB6-AD MB7-AD ST8 ST9 C10-AD C11 SN12-AD SN13 Years attended Ed Walsh Hockey Schools Shirt Size (Please over estimate 2 sizes to accomodate equipment) Men's Small Medium Large X-Large XXL (additional $5.00) List strengths or weaknesses Medical Forms Required for schools located in Massachusetts. All students must have an up to date medical examination (within the preceding 24 months) and certificate of immunization record by first day of registration. Please inform Ed Walsh Hockey Schools of any physical limitations of your player/child, such as asthma, medical alert bracelets, medications, etc. Any player that shows up for camp without these required medical forms will not be allowed to participate in the camp. Agreement of Waiver Acknowledging that ice hockey is a contact sport, I agree that Ed Walsh Hockey Schools (EWHS), its agents, representatives and employees shall not be liable to me (my child / player) for any injury or damage howsoevercaused, resulting directly or indirectly from my (child's / player's) participation in any and all activities at Ed Walsh Hockey Schools whether incurred on the ice or otherwise or in or about the buildings at any time preceding, during or subsequent to the delivery of the instructional school program and I hereby discharge (EWHS), its agents, representatives and employees from all actions, claims and demands I (my child / player) may have for any such injury and damage. I also agree that Ed Walsh Hockey Schools (EWHS), its agents, representatives and employees shall not be liable to me (my child /player) for any injury or damage howsoever caused, resulting directly or indirectly from my (child's / player's) participation in any and all activities at the Ed Walsh Hockey Schools in or about the residence of school buildings at any time during the term of instructional school program and I hereby discharge (EWHS), its agents, representatives and employees from all actions, claims and demands I (my child / player) may have for any such injury and damage. I also understand and agree that no portion of my registration fee will be refunded to me (my child / player) in the event, for whatever reason, I (my child / player) withdraws from (EWHS) instruction program. I further acknowledge and agree that Ed Walsh Hockey Schools (EWHS) does not ensure and will not be expected at any time, to ensure the safety or proper state of repair of my (child's / player's) equipment used by me (my child / player) during the (EWHS) program. I further acknowledge and agree that Ed Walsh Hockey Schools (EWHS) reserves the sole and exclusive right to use any photographs taken during the instructional school for advertising, instructional purposes or marketing without cost or charge whatsoever to (EWHS). I further acknowledge and agree that my agreements, releases and discharges herein shall bind my heirs, legal representatives and assigns and shall ensure to the benefit of (EWHS), its agents, representatives and employees and their successors and assigns. I agree fully with this waiver above and that I am the legal guardian or parent of the player being submitted for registration.