Student’s First Name:______________________________________ Student’s DOB: ______/______/________

Last Name of Parent(s): ____________________________________ First Name(s): ______________________

Address:_________________________________________  City:_____________________________________

State:____________  Zip Code: ______________      E-Mail:_________________________________________

HM. # (______)_______-__________WK. # (______)________-__________Cell # (______)_______-_________

All participants must wear full protective equipment including helmet.

(All participants are required to purchase a notebook and write down what they have learned from each session. 

Then, they should review their notes before the next session or before any practice.)

Please make checks payable to:   John Dillon

                                     Mail to:   93 Pineland Ave

                                                     Worcester, Ma. 01604

                                                     Phone:  (508) 792-2439    Email: john-dillon@charter.net
 

Amount Paid $_____________ Check #___________ Balance Due $____________ Date________________

Checks returned for insufficient funds will be charged an additional $25.00 fee.  Any cancellation of clinic is

subject to $150.00 non-refundable fee and a $25.00 processing fee. There are no refunds four weeks prior to

beginning of clinic. 

                       Waiver of Liability, Release, Assumption of Risk & Indemnity Agreement

        Participant and/or participants’ parent(s)/guardian(s) acknowledge, understand and assume all risks inherent in ice skating/Ice hockey and understand that said activities
involve risks to participant’s person including bodily injury, partial or total disability, paralysis, and death, and damages which may arise there from and that I/We have
knowledge of said  “Risks”.   These Risks may be caused by the negligence of the participant or the negligence of others, including the “releasees” identified below.

        It is the purpose of this agreement to exempt, waive and relieve, release and forever discharge releasees from liability for the Risks, personal injury, property damage, and
wrongful death caused by negligence, if any, of releasees.   “Releasees” include Dillon Skating School, John Dillon, other participants, coaches, helpers, owners and operators
of the premises used to conduct event and each of them, their officers, directors, agents and employees.  Participant and/or participant’s parent(s)/guardian(s) acknowledge
that they have been provided and have read the above paragraphs and have not relied upon any representations of releasees, that they are fully advised of the potential
dangers of ice skating/ice hockey and understand these waivers and releases are necessary to allow ice skating/ice hockey to exist in its present form. 

        Participant’s parents further agree to defend and indemnify the releasees for any claims arising from the Participants participation in the activities described herein, and or
the Risks.   Any cancellation of clinic is subject to $150.00 non-refundable fee and a $25.00 processing fee.  There are no refunds four weeks prior to beginning of clinic. 

Signature________________________________________________, Date __________________________

                   (Parent’s or legal guardian’s signature)

Please Print_____________________________________________________________________________           

                                  (Parent’s full name)