2017 FUTURE PROSPECTS COMBINE

Registration

NORTH AMERICAN HOCKEY LEAGUE

*Middletown, NJ Combine 2003-04 Combine Closed
*Simi Valley, CA Combine All Goalie Positions Full.
*Attleboro, MA Combine 2001-02 Goalie Positions Full.
*Duluth, MN Combine Goalie Positions Full.

First Name:

Last Name:

*2001-2002 birth years only for Middletown and Duluth events (no 2003-04’s)*
*2001-2004 birth years only*
Player DOB: (mm/dd/yyyy)

City:

State/Province:

Zip/Postal Code:

Home Phone:

Cell Phone:

Email:

Height:

Weight:

US Citizen?:
Yes No

If no, then what Nationality?:

Parent(s) Phone:

Parent(s) Email:

Current Team:

League:

Position:

Shot:
Left Right

Current Head Coach:

Coaches Contact Info (Email/Cell):

Personal Statistics:

(GP):

(G):

(A):

(PIMs):

Honors/Awards received in hockey in the past three years:

Do you wish to play Junior Hockey someday?(1 some interest, 5 absolutely):
1 2 3 4 5

Do you have Family Advisor or Agent?:
Yes No

Adivsor/Agent Name and Contact:

School City & State:

Overall Grade Average (Approx):

Grade entering in the fall 2017:

Hockey Reference (1) Name:

Contact:

Hockey Reference (2) Name:

Contact:

Emergency Contact (1) Name:

Relationship:

Emergency Contact (1) Home Phone:

Emergency Contact (1) Cell Phone:

Emergency Contact (2) Name:

Relationship::

Emergency Contact (2) Home Phone:

Emergency Contact (2) Cell Phone:

Family Physician Name:

Family Physician Number:

Family Physician Address:

Please list any medications being taken and include dose and frequency:

Medical Insurance Company:

Medical Insurance Company Number:

Medical Insurance Company Address:

Medical Insurance Policy Number:

Medical Insurance Group Number:

Medical Insurance Policy Holder:

Policy Holder DOB (mm/dd/yyyy)

Employer of Insured:

I, the undersigned acknowledge that I am the parent or guardian of said registrant, and do hereby grant my permission for my hockey player to attend a North American Hockey League (NAHL) Future Prospects Combine (FPC) event, and to actively and fully participate in all activities thereof and once confirmed may not receive a refund. In the event of an injury or illness during these activities, my acceptance indicates that I agree to allow medical treatment even if I cannot be contacted, and authorize NAHL Future Prospects Combine and/or the local hospital to provide the needed medical treatment they deem necessary. I hereby release North American Hockey League and the NAHL Future Prospects Combine event, all members of the program’s staff, the host ice facility and it’s staff, the local hospital and their agents, employees, and representatives, and all officers of North American Hockey League and the NAHL Future Prospects Combine from any and all claims and liability arising in any way out of its exercise of this authority.

I further acknowledge, understand, and agree that in participating in this activity there is a possibility of physical illness or injury and that I, as parent or guardian of my hockey player, am assuming the risk of such injury by his/her participation and release North American Hockey League and the NAHL Future Prospects Combine, the program’s staff, the Host Ice Rink and it’s staff, and all affiliated with or participating in the NAHL Future Prospects Combine event from all liability, claims, obligations or responsibility for personal property losses, accidents or injuries of any kind. I understand the inherent risks of the training process for being a hockey player and recognize that the NAHL Future Prospects Combine event is strenuous. I have received a copy of the schedule and understand the activities. I understand that full, legal equipment is to be worn properly at all times on ice or on the bench. I further authorize the program staff to administer non-prescription analgesics for minor medical problems such as headaches, etc. unless I have requested otherwise.

Authorization and Release Statement Acceptance: I understand and accept the above authorization and release statement.