Breakaway Hockey is proud Scott Kossbiel – Co-Director
to offer its first ever - Current Assistant Coach for
official summer hockey camp the Conard High School
for high school and college- Varsity Boy’s Hockey Team
aged female hockey players!!! - Veteran Coach and Skills
Instructor for the
Location: Newington Arena
300 Alumni Rd Skills and Game-play Connecticut Northern Lights
Girl’s Hockey Organization
Newington, CT. 06111
Clinic for Girls - Former Head Coach for the
Dates: 7/6/09 – 8/19/09
High School – College Connecticut LaZers/ WINGS
Organizations
Days: Monday & Wednesday - USA Hockey Level 4
About The Camp – a hockey school
for high school and college aged Certified Instructor
Groups and Times:
U15 - College: 630pm-730pm girls that’s goal is to enhance the - 13-year Breakaway Hockey
total development of each individual Camp Instructor with
through a strict focus on skill coaching experience on local
RESERVATIONS REQUIRED development and game play. The through national levels of
TUITION: $210 per player camp’s mission is to offer players at competition
CUT OFF DATE: 7/1/09 the high school and college level the
- Graduate of The University
opportunity to be on the ice all
of Scranton, and current
summer long, in an affordable and
graduate student of St.
high quality hockey-learning
The registration information is
environment. Joseph’s College
located on the back of this
flyer. If additional information Ken Dixon – Co-Director
The instructors will focus on
is needed, please contact the
teaching the following aspects of - Founder and President of
camp coordinator:
the game: Breakaway Enterprises Youth
- Power Skating/ Edge Control Hockey Camps
Scott Kossbiel
Breakaway Hockey - Balance/ Weight Control - Founder and President of the
PO BOX 23 - Striding/ Agility/ Speed Connecticut Northern Lights
Avon, CT. 06001 - Stick Handling
Girls Hockey Association
Phone: 860-670-2746 - Under Handling
- Founding Head Coach of
Email: scottkossbiel@sbcglobal.net - Passing
Avon/ St. Paul High School
- Shooting
- Flow Drills Boy’s Hockey Program
- Vision/ Timing/ Creativity - USA Hockey Level 4
- Position Specific Skills Certified Instructor
- A Great Deal of Competition/ - Over 25 years of coaching
Mini-Games/ Scrimmage experience from “learn-to-
- The Team Game skate” through high school
- Graduate of United States
Military Academy at West
Point
REGISTRATION FORM WAIVER
High School – College Development Clinic
Consent:
Player Information:
_______________________________________ I, ________________________, parent / guardian
Name of Applicant (please print clearly) of __________________________, a candidate
for participation in the Breakaway Hockey
________________________ _____/_____/______ Program, hereby give my consent to participate in
Home Phone Date of Birth
any and all Breakaway Hockey activities.
___________________________________________ Release of Liability/Acknowledgement of Risk:
Address Upon entering programs offered by Breakaway
Enterprises, LLC. I/We agree to abide by USA
___________________________________________ Hockey rules as currently published. I/We know
City / State / Zip
that participation in ice hockey may result in
___________________________________________ serious injuries and protective equipment does not
Home Email Address prevent all injuries to participants, and do hereby
waive, release, absolve, indemnify and agree to
Parent Information:
hold harmless Breakaway Enterprises LLC,
Breakaway Hockey, USA Hockey Incorporated,
_____________________ _____________________ the Breakaway Hockey staff, Ken Dixon, Scott Kossbiel,
Name Name and South Windsor Arena for any claim arising out of
any injury to me or my child whether the result of
_____________________ _____________________
Work # Work # negligence or for any other cause, except to the extent
and in the amount covered by accident or
_____________________ _____________________ liability insurance. In the event that my child is
Cell # Cell # injured while participating in a Breakaway Hockey
--------------------------------------------------- program, I give my permission to a qualified staff
USA Hockey Member: Yes No member to seek medical attention for my child.
Yrs Experience: ______________________
USA Hockey:
Team/League: _______________________ I agree to furnish a copy of proof of registration
with USA Hockey for the 2008-2009 season or will
Position: Goalie Forward Defense provide an additional payment of $40.00 so such
registration can take place.
Please mail your tuition of $210 (checks payable to
“Breakaway Enterprises, LLC”) and a copy of your
daughter’s USA Hockey Registration Card to: ___________________________________
(Parent or Guardian Signature required)
Breakaway Hockey
PO Box 23, Avon, CT
06001-0023
___________
Class sizes may be limited. (Date)
Cut-off date to register in 7/1/09.
---------------------------------------------------
Questions? If so please contact the co-directors:
Scott Kossbiel
860-670-2746
scottkossbiel@sbcglobal.net
Ken Dixon
860-674-1181
coachkendixon@gmail.com