DAVID ROBERTS SUMMER HOCKEY CLINIC

First Name ___________________________________________________________________________________

Last Name ___________________________________________________________________________________

Street Address _________________________________________________________________________________

City ____________________________________________ State __________ Zip __________________________

Home Phone (_____) _______________________________ Email:______________________________________

Parent’s Name(Last, First)_________________________________________________________________________(if applicable)

Contact’s Work Phone ___________________________________________________________________________

Emergency Phone ______________________________________________________________________________

Birthdate _____________ Position: __________________________

Youth Clinic:_____________________________________________________________

Cost $375 (U.S. Funds) Enrollment is limited; Please send (Check or Money Order) payable to

David Roberts Summer Hockey Clinic
1000 S. State St .
Ann Arbor , MI 48109-2201
(734)764-4600

Agreement to Participate

I/We agree to release Yost Ice Arena, The David Roberts Summer Hockey Clinic, The University of Michigan, The University of Michigan Athletic Department and its employees from all claims, actions, causes of actions, or injury resulting directly from the participation of such persons in the program. I further agree to indemnify and save harmless such parties from all claims, actions, damages or demands, including all costs and expenses incurred in defending any such claim or action.

I have read the release and understand this is a full and final release of all claims for injury and damages sustained in the Yost Arena and have read over the agreement and understand the responsibilities I have assumed there under.

_________________________________________________________ Participant’s Signature _________________________ Date

________________________________________________________ Parent/Guardian Signature _________________________ Date