Street Hockey Permission Form

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Street Hockey Permission Form Powered By Docstoc
					                 Siloam United Church Form for Youth Programs
                         One form for each participant

Please complete this form and bring it with you when you come to Siloam. This information is
for Church use only and will be kept confidential.



Name of Siloam program and date: __Saturday, June 18th Street Hockey Tournament
_____

Participant’s name: _________________________________           Age:
_____________________


Team name: ____________________________________________________________


# of Players on Team: _______              Cost: _$25/tearm_ Check when paid: ______

Participants Date of Birth: _______________________________            Grade: _______



Name of parent/ guardian and phone number: _________________________________



______________________________________________________________________



Emergency contact name and phone number for that date: _______________________



______________________________________________________________________



Allergies and/ or medical conditions that you wish Siloam to be made aware of:



______________________________________________________________________



Health card number: _____________________________________________________

(This is optional but may expedite paperwork at an emergency dept.-if required.)
If you are bringing medication to Siloam, please bring medication in original bottles and label
with your name. Please list medication that you will be bringing to the event:



I give permission for ______________________________ to attend the named Siloam
program. I have disclosed all pertinent medical information including medications. I give
permission to allow Siloam officials to give this medical information for emergency medical
attention should it be required. I permit the program’s First Aider(s) to use their judgment in
determining the extent of immediate medical care as required and the possibility of using the
emergency services of a hospital or clinic. I give permission and the legal right to Siloam for the
use and ownership of any written, audio-visual and photograph material of the above named
participant for publicity and promotional purposes. I understand that Siloam has the right to
dismiss a participant, who, in their opinion, has displayed unacceptable behavior.



Parent/guardian signature: _________________________ Date: _______________



“The use, retention and disclosure of personal information collected from this form is done in compliance with privacy legislation
including, but not limited to, The Personal Information and Electronic Documents Act. Siloam United Church does not sell, share,
lease or barter personal information.



* Please review the following mandatory equipment list. If any player does not
have mandatory equipment, they will not be allowed to play.

Equipment List:
HELMET (WITH EITHER A NO MASK – I.E. BIKE HELMET, OR A HELMET WITH A CLEAR MASK)

EYE PROTECTION (IF THE HELMET DOES NOT HAVE A CLEAR MASK)

SHIN PADS



OPTIONAL: GLOVES, ELBOW PADS, KNEE PADS, SOCKS, JOCK




Goalie Equipment requirements:
Leg Pads
HELMET WITH FACE PROTECTION (EITHER CLEAR FACE MASK OR EYE PROTECTION IF HELMET HAS NO
MASK)
BLOCKER & TRAPPER



OPTIONAL: CHEST AND SHOULDER PADS

				
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