REGISTER WITH HSA

HOCKEY SKILLS ACCELERATION APPLICATION

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Fill out remaining information and mail it with your payment to:

HSA, P.O. Box 35792 Brighton, MA. 02135-0014

Name:	_______________	___________________	Date:____________	_________________
Address:	_______________	City:_______________	State:___________	Zip:______________
Phone:	_______________	Emergency Phone:____________	Position:_________	Date of Birth:____________
Program Code:	_______________	___________________	________________	_________________
E-Mail:	_______________	___________________	__________________	_________________

WAIVER: I THE UNDERSIGNED DO HEREBY WAIVE ALL CLAIMS AGAINST THE HSA, PILGRIM ARENA, MDC, IORIO ARENA, DEXTER SCHOOL OR ANYONE ASSOCIATED WITH THESE INSTITUTIONS. I WILL ASSUME ANY RESPONSIBILITY FOR ACCIDENTS AND MEDICAL OR DENTAL EXPENSES INCURRED AS A RESULT OF PARTICIPATION IN THE HSA PROGRAM. FURTHER I RECOGNIZE THAT MY SON/DAUGHTER MUST WEAR USA HOCKEY APPROVED SAETY EQUIPMENT INCLUDING A MOUTH PIECE. THE APPLICANT IS IN GOOD HEALTH AND ABLE TO PARTICIPATE IN THE PHYSICAL ACTIVITY OF A VIGOROUS PROGRAM THAT MAY INCLUDE PHYSICAL CONTACT.

Signature:______________________________________________

[PARENT/LEGAL GUARDIAN]

Date:_____________

Make Checks/Money Orders Payable to HSA

50% DEPOSIT REQUIRED, BALANCE DUE 2 WEEKS PRIOR TO PROGRAM START

Hockey Skills Acceleration, P.O. Box 35792, Brighton, MA. 02135-0014

QUESTIONS: CALL (617) 787-2753

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