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Health Form & Waiver



IN CONSIDERATION of allowing the minor(s) (child’s name), my minor child/ward, to participate in the program, related events and activities of 12188198 Canada Inc., doing business as “Barnburner Hockey Academy” (the “Company”).

I WARRANT TO YOU THAT:

1. I am a parent/guardian having full legal responsibility for decisions regarding my minor child/ward,

2. I am familiar with the risk of serious injury and death which any participant in this program must assume,

3. I believe that my minor child/ward is physically, emotionally, and mentally able to participate in this program, and that his/her equipment is mechanically fit for his/ her use in this program,

4. I understand, and will instruct my minor child/ward, that all applicable rules for participation must always be followed and that the sole responsibility for personal safety remains with my minor child/ward, and

5. I will immediately remove my minor child/ward from participation, and notify the nearest official, if at any time I sense or observe any unusual hazard or unsafe condition or if I feel that my minor child/ ward has experienced any deterioration in his/her physical, emotional or mental fitness for continued participation in the program.

I UNDERSTAND AND AGREE, ON BEHALF OF MY MINOR CHILD/WARD, MYSELF, MY HEIRS, ASSIGNS, PERSONAL REPRESENTATIVES AND NEXT OF KIN, THAT MY EXECUTION OF THIS DOCUMENT CONSTITUTES: 

1. an unqualified ASSUMPTION OF ALL RISKS associated with participation in this program by my minor child/ward even if arising from negligence, or gross negligence, including any compounding or aggravation of injuries caused by negligent rescue operations or procedures, of the Company and any persons associated therewith or participating therein, and

2. a FULL AND FINAL RELEASE AND WAIVER OF LIABILITY of the Company and all persons and organizations associated with it and the program including, without limiting the generality of the foregoing, 12188198 Canada Inc., its officers, directors, officials, agents and/or employees, coaches, trainers, other participants, sponsors, advertisers, owners and/or lessors of the premises used to conduct the program, sanctioning bodies, medical or rescue personnel (the RELEASEES), of and from with the respect to all injury, disability, death or loss or damage to person or property whether arising from the negligence, or negligent rescue of or by the foregoing or otherwise, and

3. an UNDERSTANDING NOT TO SUE the RELEASEES for any loss, injury, costs or damages of any form or type, how so ever caused or arising, and whether directly or indirectly from the participation of my minor child/ward in the program, and

4. an AGREEMENT TO INDEMNIFY, and to SAVE and HOLD HARMLESS the RELEASEES, and each of them, from any litigation expense, legal fees, liability, damage, award or cost, of any form or type whatsoever, they may incur due to any claim made against them or any one of them whether the claim is based on the negligence or the gross negligence of the RELEASEES or otherwise.

COMMUNICABLE DISEASES INCLUDING COVID-19

ASSUMPTION OF RISK / WAIVER OF LIABILITY / INDEMNIFICATION AGREEMENT In consideration of being allowed to participate on behalf of the Company’s athletic program and related events and activities, the undersigned acknowledges, appreciates, and agrees that:

1. Participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza, and COVID-19. While rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my minor child/ward’s participation; and,

3. My child/ward and myself willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe and any unusual or significant hazard during my presence or child/ward’s participation, I will remove my minor child/ward from participation and bring such to the attention of the nearest official immediately; and,

4. I, for my minor child/ward, myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS the Releasees WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

Date signed: May 26, 2024

First Player's Name

First Name*

Last Name*
First Player's Date of Birth*
First Player's Information

Player's Team Name (if applicable)

Health Concerns (diet/allergies/chronic conditions or special considerations we should be aware of as we prepare for your participant):
First Player's Signature*
Second Player's Name

First Name*

Last Name*
Second Player's Date of Birth*
Second Player's Information

Player's Team Name (if applicable)

Health Concerns (diet/allergies/chronic conditions or special considerations we should be aware of as we prepare for your participant):
Third Player's Name

First Name*

Last Name*
Third Player's Date of Birth*
Third Player's Information

Player's Team Name (if applicable)

Health Concerns (diet/allergies/chronic conditions or special considerations we should be aware of as we prepare for your participant):
Fourth Player's Name

First Name*

Last Name*
Fourth Player's Date of Birth*
Fourth Player's Information

Player's Team Name (if applicable)

Health Concerns (diet/allergies/chronic conditions or special considerations we should be aware of as we prepare for your participant):
Fifth Player's Name

First Name*

Last Name*
Fifth Player's Date of Birth*
Fifth Player's Information

Player's Team Name (if applicable)

Health Concerns (diet/allergies/chronic conditions or special considerations we should be aware of as we prepare for your participant):
Sixth Player's Name

First Name*

Last Name*
Sixth Player's Date of Birth*
Sixth Player's Information

Player's Team Name (if applicable)

Health Concerns (diet/allergies/chronic conditions or special considerations we should be aware of as we prepare for your participant):
Seventh Player's Name

First Name*

Last Name*
Seventh Player's Date of Birth*
Seventh Player's Information

Player's Team Name (if applicable)

Health Concerns (diet/allergies/chronic conditions or special considerations we should be aware of as we prepare for your participant):
Eighth Player's Name

First Name*

Last Name*
Eighth Player's Date of Birth*
Eighth Player's Information

Player's Team Name (if applicable)

Health Concerns (diet/allergies/chronic conditions or special considerations we should be aware of as we prepare for your participant):
Ninth Player's Name

First Name*

Last Name*
Ninth Player's Date of Birth*
Ninth Player's Information

Player's Team Name (if applicable)

Health Concerns (diet/allergies/chronic conditions or special considerations we should be aware of as we prepare for your participant):
Tenth Player's Name

First Name*

Last Name*
Tenth Player's Date of Birth*
Tenth Player's Information

Player's Team Name (if applicable)

Health Concerns (diet/allergies/chronic conditions or special considerations we should be aware of as we prepare for your participant):
Emergency Contact

This section is to enter information for an emergency contact who is an alternative to the participant or parent/guardian signing below


Other Emergency Contact:

Relationship to participant

Phone #
Parent or Guardian Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Consent to use photos
Your consent is required for Barnburner Hockey Academy to publish pictures or videos of you or your child. By checking “Yes I agree” below, I understand that I am giving consent to 12188198 Canada Inc. to use and disclose my personal image (or the personal image of my child) for promotional and/or informational purposes such as social media posts, flyers, and training videos.*
Yes, I agree
No, I do not agree

FOR PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT THE TIME OF REGISTRATION)

This is to certify that I, as parent/guardian, with legal responsibility for this participant, have read and explained the provisions in this waiver/release to my child/ward including the risks of presence and participation and his/her personal responsibilities for adhering to the rules and regulations for protection against communicable diseases. Furthermore, my child/ward understands and accepts these risks and responsibilities. I for myself, my spouse, and child/ward do consent and agree to his/her release provided above for all the Releasees and myself, my spouse, and child/ward do release and agree to indemnify and hold harmless the Releasees for any and all liabilities incident to my minor child's/ward's presence or participation in these activities as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent provided by law. 



By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian Name

First Name*

Last Name*

Relationship*
Parent or Guardian Date of Birth*
Parent or Guardian Information

Player's Team Name (if applicable)

Health Concerns (diet/allergies/chronic conditions or special considerations we should be aware of as we prepare for your participant):
Parent or Guardian Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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