Name:____________________________________________________________________


Parents Name:___________________________________________________________


Address:__________________________________________________________________


Phone:____________________________________________________________________


Email:_____________________________________________________________________


Age and D.O.B____________________________________________________________


Level and Session_________________________________________________________



Liability Waiver:

I acknowledge, personally and on behalf of my child, heirs and any of his/her/my legal representatives, that Rivard's Power Skating and Hockey Academy, it's agents, officials, employees and representatives, shall not be held liable for any death, injury loss, damage, cost or expenses arising from participation in any activity directly or indirectly associated with the previously mentioned hockey program occurring on or off the ice.  My child has permission to participate in Rivard's Power Skating and Hockey Academy and I give the aforementioned Hockey Camp permission to render medical attention to my child should it be deemed necessary.


Parent/Legal Guardian:


Name:______________________________________________________________________


Signature:__________________________________________________________________


Date:_______________________________________________________________________


Please mail to:

Bill Hey

23230 McEvoy Rd, RR 2

Mount Brydges  ON  N0L 1W0



**Refunds will be issued if you cancel 30 days before your program starts**