Pinnacle Hockey Camp 2012

Head Instructor – Fred Jack

Registration Information

Please carefully complete and sign this form. $50.00 non-refundable deposit. Space is limited. Full payment may also be paid at the time of registration. If camp is full, participant registrant will be notified immediately. Balance of fees are due by July 15, 2012. Please mail completed registration form and cheque to the address below. No post-dated cheques please. NSF cheques will be subject to a $30.00 Fee. The camp for children whose Birth Year is from 2004-2006 will be held from July 30^th – August 3^rd 2012.

Please Print Legibly:

Participant’s Name___________________________________________________

Year of Birth________________________________________________________

Parent’s Name(s)____________________________________________________

Address____________________________________________________________

City/Town__________________________________ Postal Code______________

Contact Phone(______)_______________________________________________

Contact E-mail_______________________________________________________

Health Card #_______________________________________________________

Liability Waiver and Medical Release

I agree I shall provide health insurance to cover any personal injury and property damage sustained by the player while participating in any activities during Pinnacle Hockey Camp Sessions. In consideration of the participate and participant in the Pinnacle Hockey Camps, we do hereby forever release and discharge Pinnacle Hockey Camps, its directors, Employees, and any person or corporation connected herewith from all manner of action, injury, damages, costs, claims or demands which we shall or make hereafter have, suffer or receive by reason of such participant in the program. The release shall be binding on our heirs, assigns, executors and administrations. It is agreed that Pinnacle Hockey Camps does not and shall not be considered to guarantee or warrant such equipment as maybe used in conducting of the said camp. It is further agreed that the Pinnacle Hockey Camps is not responsible for the loss of stolen personal articles or hockey equipment. There are no exceptions. This is also my permission to have my child admitted and attended to for medical or dental treatment in case of sickness or injury. Your signature confirms that you have read and understood our waiver form and registration information on this paper.

Parent/Guardian Signature:_______________________________________

Total Cost $130 Incl. GST = Half Day Camp

$110 Incl. GST = On Ice Session Only

Send completed Registration form and cheque payable to:

Fred Jack

446 Twinriver RD. W

Lethbridge, AB T1J 3Y9

* Dates: July 30-August 3, 2012

* Ages: Birthyears 2004-2006

* Location: Civic Centre in Lethbridge

* Cost: $110 One-Hour Ice Instruction/Day *Option 1 (2-3pm)

* Cost: $130 Half Day Camp *Option 2 (12;30-5:00 pm)

(Ice time, snacks, activities, shooting sessions, demonstrations, craft activities)
*Price includes GST: $50 non-refundable

*Deposit & Balance must be paid by July 15, 2012

Fred's BackGround

* University of Alberta B.Ed./BPE
* 15 Years Successful Coaching Experience
* Prov. Pee Wee and Midget ‘AAA’ Champion Coach
* Okanagan Hockey School Former Head Instructor
* Education Administrator
* WHL Lethbridge Hurricanes CJOC Colour Analyst
* NCCP Trained Level IV Hockey Coach

For More Information or to Register: Mail:

446 Twinriver Road West, Lethbridge, AB, T1J 3Y9 Phone: 403-795-6700 E-Mail: freddiej@telus.net