FORT ZUMWALT WEST HOCKEY CLUB

PO Box 934 * OFallon, MO 63366 fzwhockeyclub@gmail.com

Fort Zumwalt West Hockey Club Summer Camp Permission Form

The Summer Camp Program is intended to prepare the players for the upcoming 2013-2014 hockey season. We have developed the program as a combination of on ice skills practice sessions and an off ice dry-land fitness program. The program involves hockey, fitness, weight training and class room type sessions. The players are expected to participate in all facets of the program. Summer Camp Year: Player Name: Height: Address: City, State, Zip: Home Phone: Cell Phone: Email address: PARENT NAME AND CONTACT INFORMATION Parent Name: Address: City, State, Zip: Home Phone: Cell Phone: Email address:
1

Are you a current member of USA Hockey?

Weight:

Age:

Grade Entering:

Parent Name: Address: City, State, Zip: Home Phone: Cell Phone: Email Address: CONTACT FOR EMERGENCY Name of person to contact in case of emergency: Phone number in case of emergency: Are there any medical conditions we need to be aware of? If so please explain below.

I____________________________, give my permission for _____________________ to participate in the Fort Zumwalt West Hockey Club Summer Camp. I understand that the Camp is a multi-activity camp including on ice hockey and a dry-land fitness program. I acknowledge that both hockey and fitness programs can have inherent risks of injury. I understand and acknowledge these risks and I assume all the risk by providing my permission for my child to participate in the Summer Camp Program. I understand that FZWHC will not be responsible for any injuries that may occur while my child is participating in the Summer Camp Program.

__________________________________ Parent signature ___________________ Date