Membership Application Form

SUMMER PROGRAM
1. PARTICIPANT INFO
My kid is (choose):
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Age
Hockey Club
Position Played
Sex

MF
Jersey Size
2. HEALTH INFO
Physician's Name
Phone Number

Area CodePhone Number
Health Card #
Allergies
Chronic Medical conditions
Medications
Will Player Bring Medications to Camp

YesNo
If Yes, it needs to be in the original container and properly labeled.
Does the Player Wear Eye Contacts?

YesNo
Does the player have any past or present injuries?

YesNo
If Yes, please explain:
3. PARENT/GUARDIAN INFO
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
E-mail
*Note* The email you provide above will be the email PHD Hockey Essentials will use to contact and notify parents/guardians of any updates, changes and cancellation to programs.
4. EMERGENCY CONTACT INFO
1st Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
2nd Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
5. PAYMENT INFO
Forms of payment accepted:
cheque/cash/e-transfer (info@phdhockey.net).
*note cheques/cash given in person directly to PHD staff.

Full payment is only needed once your child/participant has received confirmation of availability via email by a PHD representative. However, payment needs to be submitted before camp begins, deadlines will be posted on website and sent by email for your convenience.
* Cancelation Policy
PHD will ONLY issue refunds if notice is given more then 45 days prior to camp start date. Anytime there after, NO refunds allowed, unless medical documentation is provided.

Waiver forms need to be submitted on the first day of the camp/program. PHD Hockey Essentials will not allow child/participant to step on the ice without the waiver, and will not credit for any days loss.
* Program Policy
No partial payments allowed for missed days. PHD encourages participants to find their own replacements for any missed days.
BY SIGNING THIS FORM

I hereby acknowledge and accept the cancellation policies put in place by PHD Hockey Essentials, and do not hold PHD Hockey Essentials accountable for any lost, stolen or damaged personal property, including all hockey equipment.
Parent/Guardian Signature and Date (Typing in your name acts as your signature)
Parent/Guardian Signature and Date (Typing in your name acts as your signature)
Thanking you in advance!
Should be Empty:

SUMMER PROGRAM

1. PARTICIPANT INFO

2. HEALTH INFO

3. PARENT/GUARDIAN INFO

4. EMERGENCY CONTACT INFO

5. PAYMENT INFO

* Cancelation Policy

* Program Policy