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Dream Big HockeyStars
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Medical Release/Contact Information

Medical Release and Contact Information

General Information
Name *
DOB *
Address *
City *
State/Zip *
Parents Name *
Home Phone / Work Phone *
Cell Phone *
Emergency Phone *
Emergency Contact Information
Contact Name / Relationship *
Home Phone / Work Phone *
Cell Phone *
Contact Name / Relationship *
Home Phone / Work Phone *
Cell Phone *
Doctors Name / Phone Number *
Dentist Name / Phone Number *
Health Care Provider / Plan # / Phone Number *
Liability Waiver and Medical Release
The undersigned hereby agrees to provide evidence of health insurance for the above-named camper (including a copy of an insurance coverage card or similar document) to cover any personal injury and property damage sustained by such camper while participating in any program or activity operated by Dream Big HockeyStars, LLC (the “Company”) on the premises of the Company or on any premises leased or otherwise under the control of the Company. The undersigned assumes all responsibility for any and all risk of damage or injury that may occur to the above-named camper as a participant in any program or activity operated by the Company including without limitation, practices, scrimmages, skills sessions, clinics, day camps, boarding camps, games, tournaments, off-ice activities and any other activities related to the Company program or activity. Additionally, the undersigned hereby releases and forever discharges the Company, and its owners, subsidiaries, affiliates, directors, managers, officers, successors and assigns, operators, employees, agents, supervisors, instructors and other individuals assisting with a Company program or activity, from any and all claims, demands, rights or causes of action present or future, whether known or unknown, resulting from or arising out of the above-named camper's participation in a Company program or activity. This waiver constitutes the permission of the undersigned to have the above-named camper, while participating in a Company program or activity, admitted and attended to, for medical and dental treatment, in the case of sickness or injury, and the undersigned further acknowledges that all physicals and inoculations of the above-camper are up to date. The undersigned hereby grants the Company the right to use photographs, video images and/or other media of the above-named camper for Company publicity, advertising and/or other commercial purposes. The undersigned understands that this document is intended to be as broad and inclusive as permitted by the laws of the state in which the Company program or activity is taking place and agrees that if any portion of this waiver is deemed invalid, that the remainder of this waiver shall continue in full legal force and effect. The undersigned further agrees that any legal proceedings of any nature related to this waiver and the participation of the above-named camper in any Company program or activity shall take place in Boston, Massachusetts.
Medical Release *
Date *
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