Please print this form and send payment in full to reserve a spot.
_____ Practice & Play 10 & under________________________ $485
_____ Power & Pucks_______________________________________ $485
_____ Adult Practice & Play__________ _____________________ $520
WAIVER/AGREEMENT: I agree that I shall provide health insurance and other applicable insurance to cover any personal injury and property damage sustained by the student while participating in any activities or while on the permissive of the Doug Brown Hockey Development Program; and that in consideration of these services provided in connection with the ice skating and hockey program. I hereby and forever discharge DBHDP from all damages, causes of action, suit, or liabilities for personal injury and or property damage which I as a student or my child as a student, or myself may have as a result of participating in said program. I/WE authorize the DBHDP to seek emergency treatment for our child while a parent is being contacted. I attest that the player is of good health and is able to participate in the physical activity of a rigorous program. Pictures of you or your hockey player may be used in our flyer or on our web site.
Signature of student
Parent/Legal Guardian: _________________________________________________
Please make check payable to: Doug Brown Power Skating
P.O. Box 67 Ringwood NJ. 07456
For more information contact Doug Brown (201) 394-1866