Name				Address
City				Province
Postal Code				Email
Telephone (home)				Telephone (work)
Birth Date				Division
Level Played		AAA AA A Recreational		Medicare #
Emergency Contact				Emergency Phone
Program Requested				Program Cost
Sweater size (sweaters are not provided with all programs)
Sweater number (if sweater is provided)
I agree  with the state- ment below	Parent or Guardian			Date
I/We do hereby release Alexander Goaltending, its officers, employees, and agents from all liability, claims, or causes of action of any kind whatsoever for any injury, property loss or damages resulting directly, or indirectly from my (child's) participation in this goaltending school, whether incurred on the ice, or otherwise in or about the buildings at the program location or those used by the school at any location or during travel to or from any location, and I/we hereby discharge Alexander Goaltending, its agents, servants, and employees from any, and all future actions, claims and demands.