"Street Hockey Permission Form"
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