Mail In REP 3 on 3 TEAM ENTRY

Use Control-P to Print - Complete Form and Mail to:
AJAX PICKERING SUMMER HOCKEY, 2-157C Harwood Ave N, Suite 213 Ajax Ont L1Z 0B6
Team REP Name:________________________________________

Team Rep Address:_____________________________________________________

Phone:______________________________ E-mail (required)___________________________________________

Calibre of hockey last played (circle): 
BOYS A, AA, AAA 

GIRLS  A,AA 

Team Name: ________________________________________________________________________________________

Team Colours: (team MUST provide own sweaters) __________________________________

Division (Tyke, Novice, Atom, Peewee, Bantam )___________________________________

TEAM REP HEALTH CERTIFICATION: Upon signing this application, the team rep certifies that all players are in good normal health, are properly equipped (full hockey equipment mandatory) and have no abnormal handicaps. 

PLAYER/PARENT/GUARDIAN CONDUCT: The Ajax Summer Minor Hockey League and/or 1000724367 Ontario Ltd. operates on Municipal property with the permission of the Town of Ajax. To this end, players, parents/guardians and participants will respect the facilities and grounds and will abide by the rules set forth by the facility and staff and abide by all Local, Provincial and Federal orders to restrict transmission of COVID-19.

TEAM REP WAIVER AND INFORMED CONSENT: To whom it may concern: I, the undersigned, authorize The Ajax Summer Minor Hockey League and/or 1000724367 Ontario Ltd. and/or Town of Ajax and/or anyone acting on their behalf to acquire necessary medical aid that may be required as a result of any accident or injury which may be sustained by members of this team. I have been warned and informed via this document that insurance coverage is not provided and there are serious physical risks associated with hockey, including, but not limited to falls and/or collisions with stationary objects, other players, skates pucks and sticks and/or COVID-19 exposure. My signature below indicates my confirmation that I have explained these risks to the parents of all team members.  And I hereby indemnify and save harmless the The Ajax Summer Minor Hockey League and/or 1000724367 Ontario Ltd. and/or Town of Ajax and/or anyone acting on their behalf from any and all actions, claims and demands for damages, loss or injury however arising which here to after may have been sustained by any member of the team while participating in any activity or facility operated by The Ajax Summer Minor Hockey League and/or 1000724367 Ontario Ltd. and/or Town of Ajax. My signature below indicates that I am the team rep having the legal right to assume the conditions above on behalf of the team players named on the roster sheet. My signature below also indicates that I have thoroughly read and agree to all of the terms above. 

TEAM REP SIGNATURE ________________________ 

NOT VALID WITHOUT ROSTER SHEET INCLUDING SIGNATURES AND PAYMENT 

TEAM ENTRY FEES: $3277

DATED THIS ___DAY OF ________, 2025 NOT VALID WITHOUT SIGNATURES AND PAYMENT 

MAIL TO: AJAX PICKERING SUMMER HOCKEY, 2-157C Harwood Ave N, Suite 213 Ajax Ont L1Z 0B6
(no in-person deliveries please, mail only) (no refunds permitted)