Rousseau's Hockey Clinic

Spring 2010 Youth Application

Name:  _________________________________________

Address:  ______________________________________

City:  _________________  State: _______  Zip: ______

Birthdate:  _______ / _______ / _______

Phone:  ________________________________________

E-Mail:  _________________________________________

Current Hockey Org:  ____________________________

Shoots:                    Right   /   Left

Pref. Position:       Goalie*       Forward       Defense

Jersey Size:     Youth XL       Adult Small       Adult Medium

                                Adult Large       Adult XL

Method of Payment:       Check       Visa       Mastercard     Discover

Amount:  $____________________

Card Holder Name:  ______________________________

Card Number:  __________________________________

Expiration Date:  ________________________________

Card Holder Signature:  __________________________

Family Discount:  The first family member pays the regular tuition, each additional family member receives a 10% discount on the lesser tuition

(Please select desired location and division)

Ingersoll, Auburn

_____Micro Division (Ages 4 to 6) - $195

Saturdays at 9:30 AM beg.4/17

_____Junior Division: (Ages 6 to 8) - $395

Tuesdays at 6:15 PM beg. 4/20

_____Minor Division: (Ages 9 to 11) - $395

Wednesdays at 6:15 PM beg. 4/21

_____Senior Division: (High School) - $395

Sundays at 9:30 AM beg. 4/18

Family Ice Center, Falmouth

_____Micro Division (Ages 4 to 6) - $195

Saturdays at 9:20 AM beg.4/17

_____Junior Division: (Ages 6 to 8) - $395

Saturdays at 7:00 AM beg.4/17

_____Minor Division: (Ages 9 to 11) - $395

Mondays at 6:10 PM beg. 4/19

_____Major Division: (Ages 12 to 15) - $395

Sundays at 9:30 AM beg. 4/18

* Goalies skate for a reduced tuition of $200

Please Return with a
$150.00 Deposit payable to

Rousseau
8 Danbury Drive
Auburn, Maine 04210
or
Fax it to (207) 784-2821
(Spring Clinic Deposits are non-refundable after 3/1/10)

I hereby give permission for my child (named above) to participate in the hockey clinic(s) offered by Rousseau’s Hockey Clinic, Inc. in the Spring of 2010.  In consideration of Rousseau’s Hockey Clinic, Inc., its employees, agents, representatives, helpers, sub-contractors and employees (hereinafter “staff”), undertaking to instruct the applicant at a hockey clinic(s) held at the Ingersol Arena and Family Ice Center (hereinafter “facilities”) in the Spring of 2010, my child (named above) and I agree to assume the risks associated with said hockey clinic(s) and hereby release and forever discharge, and agree to defend, indemnify and hold harmless Rousseau’s Hockey Clinic, Inc and its staff and the facilities 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 child’s (named above) participation in said hockey clinic(s), 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 facilities and their staff as set forth herein. My child and I acknowledge and agree that Rousseau’s Hockey Clinic, Inc. and its staff and the facilities and their staff accept no responsibility for or on account of any injury or damage, both to person or property, to my child arising out of all acts of negligence or negligent conduct by Rousseau’s Hockey Clinic, Inc. and its staff and the facilities and their staff or otherwise.  My child and 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 of Legal Guardian:_____________________________________________ Date:______________