100 Mile House Wranglers
2014/2015 Spring Prospects Camp
April 25 – April 27, 2014
Location: South Cariboo Rec Center, 100 Mile House, BC
Check in: April 25th between 11am and 2pm at the South Cariboo Rec Center
Details: A minimum of 4 ice times will be provided between April 25th and the afternoon of April 27th. An
All-Star Game will occur Sunday afternoon.
Camp Fee: The camp fee is $180 + GST ($189.00) per player or $225 + GST ($236.25) for Goaltenders.
This fee will not be charged to your credit card until you are confirmed to have been accepted into the
Spring Camp. No refunds will be issued on camp registrations once accepted and processed.
The Camp Registration form must be scanned and submitted electronically. Please scan and email your
camp registration to GM / Head Coach, Doug Rogers at doug.rogers@100milewranglers.com for
consideration. Once the registration/application has been reviewed and considered, a confirmation email
will be sent to the email address provided on the registration form. Hotmail addresses please check your
junk mail regularly as on occasion our emails are incorrectly filtered by hotmail accounts.
In order for your registration form to be considered, the form must be fully completed. Incomplete forms
will not be processed and returned.
If you would like to be considered for our spring camp, please make sure that your registration
form is received early.
100 Mile House Wranglers
2014/2015 Spring Prospects Camp
April 25 – April 27, 2014
Personal Information:
Name: _______________________________________________________________________________________________
Email: ________________________________________________________________________________________________
Mailing Address: ________________________________________________________________________________________
City: _________________________________________ Prov/State: _______ Postal/Zip: ______________________________
Parent/Guardian Name: __________________________________________________________________________________
Date of Birth: _________________________________
Place of Birth: __________________________________________
Height: ______
Weight: ________
Telephone #:________________________________________
Shoots: Right
☐
Left ☐
Cell #:__________________________________________
2013-2014 Hockey Information:
Team Name, League and Category (Tier):____________________________________________________________________
Coach’s Name: __________________________________________ Coach’s Email: __________________________________
Position: _________
Goalies Only: Catch
GP: _____ Goals__________
Left ☐
Assists: ________
Right
☐ Save %:___________
+/-:____________
Academic Information:
School Name (if not graduated):_____________________________________________
PIMs: ______
Grade Completed: _____
Payment Information ($189 or $236.25) (NON – REFUNDABLE ONCE PROCESSED)
By signing below, you authorize $189 or $236.25 to be charged to your Credit Card by the Wranglers organization.
Payment method: Visa ☐
Mastercard ☐
Credit card #:_______________________________________________________
Expiry Date: ________________________ CVS# (located on the back of the card):____________
Postal Code (of the address the credit card bill is sent to): _________________________________________
Cardholder Name: ________________________________________ Signature: _____________________________________
If you are already carded with ANY JUNIOR HOCKEY CLUB, please disregard this Camp Notice and/or Camp Invitation
unless you have been released or have written permission from your club to attend.
100 Mile House Wranglers
2014/2015 Spring Prospects Camp
Medical Questionnaire
April 25 – April 27, 2014
Personal Information:
Name: __________________________________________________ Age: _______ Birthdate: ________________________
BC Medical Plan:
Yes ☐
No ☐
Care Card Number: _________________________________________________
Other Provincial Insurance and/or Additional or Extended Health Insurance: Yes
☐
No ☐
Province of Coverage (if not BC): _______________________ Health Care Number: _________________________________
Name of Out of Province (if not BC) Insurance Company: _______________________________________________________
Extended Health Policy # (if applicable): _____________________________________________________________________
Family Doctor Name: ____________________________________ Phone: _________________________________________
Your Mailing Address: ___________________________________________________________________________________
City: ________________________________________ Prov/State: ________Postal/Zip: ______________________________
Emergency Contact Person’s Name: _______________________________________________________________________
Phone: (H) ______________________________________ (Cell) ________________________________________________
Please provide any and all medical information that you feel the Wranglers’ Organization should be aware of concerning the
player (attach additional page(s) if necessary):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
I understand that it is my responsibility to immediately advise Camp Training Staff of any change in the above information or
overall medical condition. In the event that no one can be contacted, the Training Staff or Management will admit the player to
the hospital if deemed necessary.
Authorization is hereby provided to the training staff as well as the first responders, physicians and nursing staff of any Hospital
or Emergency Unit to undertake necessary examination, investigation and necessary treatment of the player.
Date: __________________________ Players Signature: __________________________________________
Date: __________________________ Parent or Guardian Signature: _________________________________
(Parent or Guardian MUST sign if player is under the age of 18)
Waiver
In consideration of being allowed to participate in any way in the
Wranglers’ Hockey Camp, related events and activities, the
undersigned acknowledges, appreciates, accepts and agrees that:
1. The risk of injury from activities involved in this program is significant, including the potential for permanent paralysis and
death, while particular rules, equipment, and personal disciplines will reduce this risk, the risk of serious injury does exist;
and
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown. EVEN ARISING FROM THE
NEGLIGENCE OF THE RELEASES or others and assume full responsibility for my participation; and
3. I willing agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any
unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the
attention of the nearest official immediately; and
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD
HARMLESS the 100 Mile House Wranglers Jr B Hockey Club, their officers, directors, officials, agents, sponsors, advertisers,
and if applicable owners and lesser or premises used to conduct the event releases WITH RESPECT TO ANY AND ALL
INJURY, DISABILITY, DEATH or loss or damage to a person or property, WHETHER CAUSED BY NEGLIGENCE OF
RELEASES OR OTHERWISE.
I have read this release of liability and assumption of risk agreement, fully understanding its terms, understand that I have given
up substantial rights by signing it and sign it freely and voluntarily without inducement.
Participant signature: ___________________________________________________
Date Signed: __________________________________________________________
Witness: ______________________________________________________________
For Participant of Minor Age (under 18 years of age is at time of registration)
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his release as
provided above, of all the releases and for myself, my heirs, assigns, and next of kin, I release and agree to indemnify the
Release for any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above.
Parent/Guardian Signature: _________________________________________________
Date Signed: ____________________________________________________________
Witness: _______________________________________________________________
Emergency Telephone #: __________________________________________________