Please Check All That Apply:

1/2 session  One-on-One Coaching $30

 Full session One-on-One Coaching $60

NAME

ADDRESS

CITY

STATE

ZIP

HOME PHONE

EMAIL ADDRESS

EMERGENCY PHONE

AGE

CURRENT GRADE

POSITION

EXPERIENCE

PARENT/GUARDIAN RELEASE:

As parent or legal guardian of this camper, I understand and accept the risk of injury. I authorize the directors to act for me according to their best judgment in any emergency requiring medical attention. I hearby waive all claims against Extreme Field Hockey, its employees and The Town of Canton for any injuries however so occasioned.

Parent/ Guardian Signature:

Medical Coverage:

Policy Number: