Monsignor Bonner Ice Hockey
Dear Parents;
April 15, 2008
Monsignor Bonner Ice Hockey is celebrating the start of its 38th season of high school hockey. And
what changes we’ve seen over those thirty-eight years! The program has grown into one that competes on
several different levels, and has seen much success along with its growth. The 2007-2008 season brought us
our fifth Eastern League Junior Varsity Champiuonship.
Enclosed you will find the program’s Registration Packet. It contains all the necessary information
and forms you will need to complete in order to register your child for the program. They must be completed
before your child may participate in the pre-season tryouts. Although some may seem redundant, each is
required for different purposes. Please make sure that each form has all the information requested. The
packet contains the following:
 Registration Instructions
 USA Hockey Consent to Treat (both sides)
 EHSHL Registration Form
 USA Hockey Waiver of Liability
 Pre-Participation Sports Physical Examination
 Certified Copy of Birth Certificate – Please provide
Please complete the USA Hockey Consent to Treat (both sides), the EHSHL Registration Form, the USA
Hockey Waiver of Liability, and the Physical Form and return them by Friday, May 30th. A $75 nonrefundable registration fee, made payable to “Monsignor Bonner Hockey Club,” is due at this time and
should be sent along with the forms. Tuition for 2008-2009 has not been established as contracts are being
negotiated for ice, league dues, referee fees, & trainer fees etc.
We plan on competing at the following levels; based on the number of participants:
 Varsity I AAA – Tier 1
Eastern High School Hockey League (AAA-Crossover)
 Junior Varsity AAA – Tier 1
EHSHL
The first installment of $350.00 is due by June 30th. The second installment of $350.00 is due by August
31st. The remaining balance is due by October 1st.
The Monsignor Bonner Ice Hockey program looks forward to another successful season with you
and your children. If you have any questions about the registration materials or the Bonner Hockey program,
please send an e-mail to Bubba@bonnerhockey.com. Thank you for your support of the program, and for the
support you give your player!
Sincerely,
Mike (Bubba) Barry and the
Msgr. Bonner Ice Hockey Staff
2008-09 E H S H L Eastern High School Hockey League
PLAYER REGISTRATION FORM
NAME:
SCHOOL:
STREET ADDRESS:
CURRENT GRADE:
CITY, STATE, ZIP:
TEAM:
PHONE:
BIRTHDATE:
________/________/________
JV
HEIGHT:
JERSEY NUMBER:
WEIGHT:
POSITION:
VARSITY
YEAR ENTERED 9th GRADE FIRST TIME:
SCHOOL ATTENDED LAST YEAR:
AGREEMENT FOR PARTICIPATION, MEDICAL AUTHORIZATION AND HOLD HARMLESS AGREEMENT
We, the parents and/or the legal guardians of the above named participant give permission and approval for his/her participation in any
and all activities of the EASTERN HIGH SCHOOL HOCKEY LEAGUE AND MONSIGNOR BONNER HIGH SCHOOL ICE HOCKEY
CLUB, commencing June 1, 2008 and ending May 30, 2009. We certify that the named participant is a member on good standing of the
team above-named, and of Monsignor Bonner High School, where he/she is a matriculating student, and that he/she has not been
suspended from either the team or the school for any reason, as of this date.
We further certify that the named participant meets the eligibility requirements of the EASTERN HIGH SCHOOL HOCKEY LEAGUE
(Article XI, Section C of the EHSHL By-Laws):
1.
To be eligible to play, team members must attend the school for which they play.
2.
The player must be in at least the ninth (9th) grade and not beyond the twelfth (12th) grade to play at the varsity level.
A player has four consecutive years of eligibility from the time the player first entered the ninth grade of any school.
3.
The player’s age on September 1st of the current season must not exceed eighteen (18).
4.
Any player suspended by school authorities shall not be eligible to compete in any League scheduled season or
post season contests. This suspension is in effect until payer-student is re-instated by school authorities.
5.
Any player under suspension by League officials for violation of playing rules is not eligible for League scheduled
season, post season contests, or All Star game until said suspension is expired.
To the best of our knowledge the named participant is physically able to participate in any team or League activity, game or practice.
Further, we do release, absolve, indemnify and hold harmless both the EASTERN HIGH SCHOOL HOCKEY LEAGUE and the team
above named from any injury or liability to the named participant sustained or resulting in any manner whatsoever from participation in
the activities of the League and the team above named; including, but not limited to, practices, games and travel to and from such
events.
We authorize any League coach, assistant coach or official to have the named participant examined and/or treated by a physician and, if
necessary, admitted to a hospital for medical care.
I/We have read this statement in its entirety and fully understand its meaning and intent:
(SEAL) __________________________________________
DATE ________________ RELATIONSHIP __________
(SEAL) __________________________________________
DATE ________________ RELATIONSHIP __________
Signature of Participant (if over 18) __________________________________________________ DATE ___________
2008-09 PRE-PARTICIPATION SPORTS PHYSICAL EXAMINATION
NAME: _________________________________________________________ DATE: _______________
SPORT: __
Ice Hockey_______________ AGE: ______________ DATE OF BIRTH: ____________
Height:
Weight:
Percent Body Fat:
Medical Examination
EENT
Cardiopulmonary
Lungs
Abdomen
Genitourinary
Neurological
Skin
Other
Musculoskeletal Exam
Scoliosis
Special Tests
(Based on History Form)
Neck
Shoulder
Elbow
Wrist
Hand
Back
Knee
Ankle
Foot
Other
BP:
/
Pulse:
Recheck B/P:
Normal
Handed:
R
or
L
/
Abnormal Findings
Initials
CLEARANCE:
A. Cleared _______/_______/_______
B. Cleared after completing evaluation/rehabilitation for:__________________________________
C. Not Cleared for:
Collision
Contact
Non-contact
Strenuous
Moderately Strenuous
Non-strenuous
Due to:___________________________________________________________________
Recommendation: _______________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________
Name of Physician: _____________________________________________________
Date: __________
Address: _____________________________________________________________
Phone: _________
Signature of Physician: __________________________________________________
USA HOCKEY
Monsignor Bonner Ice Hockey
CONSENT TO TREAT
This is to certify that on this date, I _______________________________________________, as parent or guardian of
(Parent/guardian)
___________________________________________________________, give my consent to USA Hockey and its
(Player)
medical representative to obtain medical care from any licensed physician, hospital, or clinic for the above-mentioned
athlete, for any injury that could arise from participation in USA Hockey-sanctioned events.
If said athlete is covered by an insurance company, please complete the following:
Name of Insurance Company: _____________________________________________
Address: ______________________________________________________________
Policy Number: _________________________________________________________
Signed: _______________________________________________________________
Relationship to athlete: ___________________________________________________
Home Address: _________________________________________________________
(Parent/guardian)
Home Phone: (_____) ________________________ Date: _______/_______/_______
Excess accident insurance up to $25,000, subject to deductibles, exclusions and certain limitations, is provided to all
USA Hockey registered team participants. For further details call Lisa Flores, Talbot Agency, Inc., (505) 828-4064. To
file an excess accident claim, call AIG, (800) 551-0824.
Mother: ____________________________________ Day Phone: (_____) __________
E-Mail address: _________________________________________________________
Father: ____________________________________ Day Phone: (_____) __________
E-Mail address: _________________________________________________________
Marital Status:
 Married
 Divorced
 Single
 Widow/Widower
MEDICAL HISTORY FORM
Name:________________________________________________________
Today’s date: ________________________
Address: ______________________________________________________
Birth date: ___________________________
______________________________________________________
Daytime Phone: (_______) ______________________
Soc. Sec. #: _________________________
Evening Phone (_______) _______________________
WHO TO CONTACT IN CASE OF AN EMERGENCY
Name: ________________________________________________________
Daytime Phone: (_______) ______________________
Relationship: _________________________
Evening Phone (_______) _______________________
Physician’s Name: _____________________________________________________________________________________
Daytime Phone: (_______) ______________________
Evening Phone (_______) _______________________
Hospital of Choice: _____________________________________________________________________________________
PLEASE COMPLETE THE FOLLOWING:
If the answer to any of the following questions is or was “yes,” please describe the problem and its implications for proper first aid
treatment on a separate piece of paper.
Have you had (or do you presently have) any of the following?
Head injury (concussion, skull fracture)
Fainting spells
Convulsions/epilepsy
Neck or back injury
Asthma
High blood pressure
Kidney problems
Hernia
Diabetes
Heart murmur
Allergies
Please specify: __________________________________
Injuries to:
Shoulder
Knee
Ankle
Fingers
Arm
Other: ________________________________________________
Impaired vision
Impaired hearing
Other: ________________________________________________
Have you had a recent tetanus booster? _________
Circle One
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
If so, when? _______________________________________
Are you currently taking any medications? _________ If so, what? Why? __________________________________
_____________________________________________________________________________________________
Has your doctor placed any restrictions on your activity? _________
If so, explain: _______________________
_____________________________________________________________________________________________
Signed (Athlete) : ______________________________________________________
Date: _____________________
Signed (Parent): ______________________________________________________
Date: _____________________
www.BonnerHockey.com
USA HOCKEY
Monsignor Bonner Ice Hockey
WAIVER OF LIABILITY, RELEASE
ASSUMPTION OF RISK & INDEMNITY AGREEMENT
For and in consideration of the undersigned participant’s registration with USA Hockey, Inc., its affiliates, local associations and member teams (all
referred to together as USAH) and being allowed to participate in USAH events and member team activities, participant (and the parent(s) or legal
guardian(s) of participant, if applicable) waive, release and relinquish any and all claims for liability and cause(s) of action, including for personal
injury, property damage or wrongful death occurring to participant, arising out of participation on USAH events, member team activities, the sport of
ice hockey, and/or activities incidental thereto whenever or however they occur and for such period said activities may continue, and by this
agreement any such claims, rights, and causes of action that participant (and participant’s parent(s) or legal guardian(s), if applicable) may have are
hereby waived, released and relinquished, and participant (and parent(s)/guardian(s), if applicable) does(do) so on behalf of my/our and participant’s
heirs, executors, administrators and assigns.
If the law in any controlling jurisdiction renders any part of this agreement unenforceable, the remainder of this agreement shall
nevertheless remain enforceable to the full extent, if any, allowed by controlling law. This agreement affects your legal rights, and you
may wish to consult an attorney concerning this agreement.
Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge, understand and assume all risks relating to ice hockey
and any member team’s activities, and understand that ice hockey and member team activities involve risk to participant’s person
including bodily injury, partial or total disability, paralysis and death, and damages which may arise therefrom and that I/we have full
knowledge of said risks. These risks and dangers may be caused by the negligence of the participant or the negligence of others,
including the “releasees” identified below. These risks and dangers include, but are not limited to, those arising from participating with
bigger, faster and stronger participants, and these risks and dangers will increase if participant participates in ice hockey and member
team activities in an age group above that which participant would normally participate in. I/We further acknowledge that there may be
risks and dangers not known to us or not reasonably foreseeable at this time. Participant (and participant’s parent(s)/guardian(s), if
applicable) acknowledge, understand and agree that all of the risks and dangers described throughout this agreement, including those
caused by the negligence of participant and/or others, are included within the waiver, release and relinquishment described in the
preceding paragraph. I/We agree to abide by and be bound under the rules of USA Hockey, including the By-Laws of the corporation
and the arbitration clause provisions, as currently published. Copies are available to USA Hockey members upon written request.
Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge, understand and assume the risks, if any, arising from the
conditions and use of ice hockey rinks and related premises and acknowledge and understand that included within the scope of this
waiver and release is any cause of action (including any cause of action based on negligence) arising from the performance, or failure to
perform, maintenance, inspection, supervision or control of said areas and for the failure to warn of dangerous conditions existing at said
rinks, for negligent selection of certain releasees, or negligent supervision or instruction by releasees.
Participant (and participant’s parent(s)/guardian(s), if applicable) agree if any claim for participant’s personal injury or wrongful death is
commenced against releasees, he/she shall defend, indemnify and save harmless releasees from any and all claims or causes of action
by whomever or wherever made or presented for participant’s personal injuries, property damage or wrongful death.
It is the purpose of this agreement to exempt, waive and relieve releasees from liability for personal injury, property damage, and
wrongful death, including if caused by negligence, including the negligence, if any, of releasees. “Releasees” include USA Hockey, Inc.,
its affiliates associations, local associations, member teams, event hosts, other participants, coaches, officials, sponsors, advertisers,
owners and operators of the premises used to conduct any event and each of them, their officers, directors, agents and employees.
Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge that they have been provided and have read the above
paragraphs and have not relied upon any representations of releasees, that they are fully advised of the potential dangers of ice hockey
and understand these waivers and releases are necessary to allow amateur ice hockey to exist in its present form. Significant
exclusions may apply to USA Hockey’s insurance policies, which could affect any coverage. For example, there is no liability coverage
for claims of one player against another player. Read your brochure carefully and, if you have any questions, contact USA Hockey or a
District Risk Manager.
______________________________________________
Age: _____
Date: ________ Signed: ______
PARTICIPANT SIGNATURE
______________________________________________
PARTICIPANT NAME (PRINT)
______________________________________________
PARENT OR GUARDIAN SIGNATURE
(if participant is 17 years of age or younger)
www.BonnerHockey.com
Date Signed: ____________________