subject_line
General Registration
Child's Information
Child's First Name
*
Programs completed
*
Learn to skate
Learn to skate and Learn to play
None
Childs Last Name
*
Sex
*
Male
Female
Age
*
Date of Birth
*
+
Ethnicity
*
Asian
African American
Hispanic
Middle Eastern
Native American
Caucasian
Other
Allergies, Asthma, Or Medical Conditions?
*
Need To Borrow Equipment?
*
No
Yes
Select Equipment Fitting Date
*
9/25/23 2-6pm RIVERSIDE
9/26/23 2-6pm RIVERSIDE
Does Not Need Equipment
New To Hasek's Heroes
*
No
Yes
Parent/Guardian's Information
First Name
*
Last Name
*
Address
*
City
*
Zip/Postal Code
*
Phone
*
Email Address
*
Email Address 2
Gross Household Income
*
less than $25,000
$25,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
Household Size
*
Emergency Contact
First Name
*
Last Name
*
Phone
*
Relationship
*
Parent/Guardian Agreement and Authorization
I, the custodial parent or guardian of the aforementioned candidate for the DHYHL hockey program hereby give my approval to his/her participation in any and all activities of this program during the 2021-2022 season. I assume all risks and hazards incidental to such participation, including transportation to and from such activities and do hereby waive, release, absolve, indemnify and agree to hold harmless the DHYHL, the organizers, supervisors, sponsors, participants and persons transporting my child to and from activities, for any claim arising out of an accident or injury to my child, except to the extent and in the event covered by accident and/ or liability insurance held by the DHYHL. I agree [give my permission for the player listed on this form] to be photographed, videotaped, or interviewed by any television, radio, newspaper, magazine, private person or group, and that the gathered material may be transmitted by electronic media or otherwise used in DHYHL published materials or in other ways for the enhancement of the DHYHL program. I have read this acknowledgement and do hereby demonstrate my understanding and agreement to abide by these guidelines by affixing my signature and the date below. Furthermore, I affirm that all the information provided on this form is true. I understand that if I knowingly give false statements, such action could be grounds for denial or dismissal from the Hasek's Heroes Program.
*
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