Rousseau's Hockey Clinic

Spring 2010 Adult Application

 

 

Name:  _________________________________________

Address:  ______________________________________

City:  _________________  State: _______  Zip: ______

Birthdate:  _______ / _______ / _______

Phone:  ________________________________________

E-Mail:  _________________________________________

Shoots:                    Right   /   Left

Pref. Position:       Goalie       Forward       Defense

Jersey Size:     Adult Large       Adult XL       Adult XXL

 

Method of Payment:     Check       Visa       Mastercard      Discover

Amount:  $____________________

Card Holder Name:  ______________________________

Card Number:  __________________________________

Expiration Date:  ________________________________

Card Holder Signature:  __________________________

 

 

 

Divisions: (Please select the desired division)
 

 

 

____Adult Woman’s Clinic - $220

Ingersol Arena, Auburn on Thursday evening

at 7:30 PM beginning March 11

 

 

____Adult Men’s Clinic - $220

Family Ice Center, Falmouth on Tuesday evenings

at 7:20 PM beginning March 9

 

 



 

Please Return with a
$100.00 Deposit payable
to
Rousseau
8 Danbury Drive
Auburn, Maine 04210
or
Fax it to (207) 784-2821

(Deposits are non-refundable after 2/15/10)
 

In consideration of Rousseau’s Hockey Clinic, Inc., its employees, agents, representatives, helpers, sub-contractors and employees (hereinafter “staff”), undertaking to instruct me at a hockey clinic held at the Family Ice Center and Ingersol Arena in the Spring of 2010, I agree to assume the risks associated with said hockey clinic and hereby release and forever discharge, and agree to defend, indemnify and hold harmless Rousseau’s Hockey Clinic, Inc and its staff and the Family Ice Center and Ingersol Arena and their employees, agents, and representatives from any liability, claims, demands, damages, causes of actions or suits of any kind or nature for injuries or damages both to person and property, that may occur as a result of my participation in said hockey clinic, including, but not limited to those arising from all acts of negligence or negligent conduct of Rousseau’s Hockey Clinic, Inc. its staff and the Family Ice Center and Ingersol Arena and their staff as set forth herein. I acknowledge and agree that Rousseau’s Hockey Clinic, Inc. and its staff and the Family Ice Center and Ingersol Arena and their staff accept no responsibility for or on account of any injury or damage, both to person or property, to me arising out of all acts of negligence or negligent conduct by Rousseau’s Hockey Clinic, Inc. and its staff and the Family Ice Center and Ingersol Arena and their staff or otherwise.  I acknowledge that this release is intended to be a complete and unconditional release of all liability to the greatest extent allowed by law.

Signature:_____________________________________________ Date:______________