Brad Buetow School of Hockey
Checking Clinic Registration

INSTRUCTIONS: Print and mail this form including your check payable to Brad Buetow for $80 to:

Brad Buetow
1419 Alamo Ave.
Colorado, Springs, CO 80907
719 473-5175 (phone and fax)

Confirmation: Your cancelled check is your proof of  enrollment. We will contact you if sessions are filled.

Player's Name: ___________________________________ Age: ___________
Address: _________________________________________________________
City: _____________________  State: ___________ Zip: ________________
Home Phone: ___________________ Work Phone: _____________________

Check One:

Players must have own insurance
The applicant agrees that Brad Buetow will not be held responsible for any accidents caused, and agrees to release the proprietors from all claims or damages which may arise as a result of or by reason of such accidents or loss. I also certify that my child has not special health problems of which I am now aware and can participate fully in the Clinic. I herby give permission to the physical selected by the program to hospitalize and secure treatment for my child.

Signature of Parent or Guardian ____________________________ Date _________