Send To: Hockey Techniques PO Box 401 Oxford, NJ 07863 or Fax to: (908) 453 - 2436
For questions call: (908) 453 - 2436 or email: hocktech@hockey-techniques.com

MEDICAL FORM

(Summer campers only)
(Please Print)

Name _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _
(Last) (First) (Middle Initial)

Camps Signed up for
1st camp ____, 2nd Camp ____, 3rd Camp__

Date of Birth _ _ _ _/ _ _ _ _ / _ _ _ _
EmailAddress:_____________________________
Mother Name:_ _ _ _ _ _ _ Home #:_ _ _ _ _ _
Work #:_ _ _ _ _ _ _ _ _ _ Cell #:_ _ _ __ _ _ _
Father Name:_ _ _ _ _ _ _ Home #: _ _ _ _ _ _
Work #:_ _ _ _ _ _ _ _ _ _ Cell #:_ _ _ __ _ _ _

IMMUNIZATIONS & OTHER PERSONAL INFORMATION

Yes No Up to Date

Measles                                      _ _ _ __        Tetanus (Initial,booster)              _ _ _ _ _ _ German Measles                          _ _ _ _ _       Rubella                                _ _ _ _ _ _
Seizure Disorder                         _ _ _ _ _ _      Mumps                                      _ _ _ _ _ _
Allergies (attach note)          _ _ _ _ _ _     Polio (4 doses,oral,vaccine,sabin) _ _ _ _ _ _

Are you on any medications? Yes______ No______ What and Why? _ _ _ _ _ _ _ _ _ _ _

Does your child have ADD or ADHD?______ Does your child have any learning disabilities? Yes______ No______ Please explain _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Does your child have any allergies?
Yes______ No______ Please explain _ _ _ _ _ _

Have you had any significant injuries in the past? (i.e. broken bones, concussions, or any surgery)
Yes______ No______ Please explain _ _ _ _ _ _

INSURANCE INFORMATION

Policy Holder: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Policy or Suffix #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Company Policy held with: _ _ _ _ _ _ _ _ _ _ _
Relationship to holder: _ _ _ _ _ _ _ _ _ _ _ _

EMERGENCY INFORMATION
(IF PARENT OR GUARDIAN CAN NOT BE REACHED)

Name _ _ _ _ __ _ _ _ _ _ _ __ _ _ _ _ __ Relationship _ _ _ __ _ _ _ _ _ _
Telephone: Home:_ _ _ _ _ _ _ _ _ _
Work:_ _ _ _ _ _ _ _ _ _ Cell:_ _ _ _ _ _ _ _ _ _

WAIVER

I/we agree with all registration/cancellation/refund policies. I/we also acknowledge that hockey is a contact sport and that the activities associated with and on the premises of Drevitch’s Hockey Techniques, LLC. program constitutes a risk of personal injury, which includes but is not limited to paralysis, permanent disabilities, and or death. In consideration of this, I agree to provide health insurance and appropriate insurance to cover any personal injury or property damage while on the premises of Drevitch’s Hockey Techniques, LLC. I attest that the player is of good health and is able to participate in the physical activities of a rigorous program. In addition to this, I give Drevitch’s Hockey Techniques, LLC consent to follow proper emergency procedure with my son/daughter. I/we will not hold Drevitch’s Hockey Techniques, LLC responsible for items lost, stolen or damaged in and around the premises of the program. I/we hereby release and forever discharge Drevitch’s Hockey Techniques, LLC, its coaches, staff, and agents from all damages, causes of action, suits or liable for any accidents, personal injury and or property damage which I/we as a student, or my child as a student, or myself may have as a result of participating in said program. I/we also give Drevitch’s Hockey Techniques, LLC permission to use any pictures and videos taken during the program for research, instruction, and/or advertising purposes.

Signature of Parent/Guardian:______________
Print name:______________ Date: ____