Capital City Condors Hockey

Participants 16 yrs and older Application Form

2014– 2015 October – March

Is this a transfer application from another team?

Yes** No

Participants are youth age 6 years and up at the time of registration. Only participants who are ineligible to play on any other team currently offered in the City of Ottawa due to a physical and/or intellectual disability will be considered.

Acceptance into the program is dependent on your athlete’s needs, the number of volunteer coaches, and the results of the reference letter*.

NOTE:Submitting a registration package does not guarantee acceptance into the Condors program. The Condors reserves the right to refuse registration at the discretion of the Registrar and/or the Board of Directors.

You will be notified shortly as to your athlete’s acceptance status.

Please return the completed and signed application form, liability waiver, media release form, and letter of reference form along with payment to:

Capital City Condors

146 Post Rd

Kanata, ON K2L 1L2

or email to:

* If the applicant has previously played hockey or this is a transfer request application, the reference form must be completed by a coaching member of the former hockey club.

PAYMENT:

The registration fee for the Condors hockey program is $325.00per player.

Please include a separate $85 jersey deposit cheque per playerdated for May 1, 2015. Upon jersey return in acceptable condition at the end of the season, deposit cheques will be destroyed.

Please note: Both cheques must accompany the application form.

Cheques should be made payable to the: Capital City Condors.

Section 1

PARTICIPANT INFORMATION: Please complete all of the following:

Athlete's Name: ______

Male ____ Female ____ Date of Birth (M/D/Y):______

Address: ______

Phone#: ______

Parent/Guardian Names: ______

Parent/Guardian Address (if different from above): ______

Parent Cell: ______

Email Address:______

(these email addresses will be added to the Condors mailing lists and as such will be available to coaches and other parents but will not be forwarded to any outside parties)

Section 2

MEDICAL BACKGROUND:

Any information provided in the medical and functional sections listed below will be treated with the strictest confidentiality. Should any information be passed beyond the directors and coaches, permission will be sought from the guardian or parent prior to releasing among team officials.

We encourage all families to have a proactive health care plan, including regular physical examinations. Capital City Condors Hockey will not assume any financial or legal responsibility for the health care of the athlete.

1. Medical Diagnosis ______

For Players with Downs Syndrome, please include test results for Atlanto-axial dislocation:
Positive ____
Negative ____ (Please include a copy of the test results.)

2. How does the medical diagnosis affect your child?

a) Physically ______

b) Cognitively ______

c) Socially ______

3. Medical Precautions (seizures, respiratory, medications, etc.)

______

  1. Allergies:
  2. Drugs ______
  3. Insect Stings or Bites ______
  4. Food ______
  5. Other ______
  1. Any recent (within the last 5 years) serious injuries or operations?:

______

______

FUNCTIONAL OVERVIEW:

  1. Does your child require any equipment to perform everyday tasks (wheelchair, braces, etc.)?

______

  1. Describe your child’s behaviour in terms of activity level, attention span, and impulsiveness:

______

  1. Please identify any triggers that may initiate negative behaviour:

______

  1. Please indicate any strategies/techniques/advice that you find useful in managing your child’s behaviour:

______

______

5. Please answer the following questions on a scale of 1 to 5

(1 being dependent or very hard and 5 being independent or very easy)

1 / 2 / 3 / 4 / 5
Level of Independence: / In mobility
In transfer (Floor to chair, etc.)
Ability of your child to / In General
communicate with new people: / To get the attention of others
To ask for help
To communicate basic needs
(i.e. Personal care)
Ability to Learn / A new recreational activity

Section 3

HOCKEY BACKGROUND:

  1. Has your child participated in skating and/or hockey before?

Yes____ No ____

If yes, did you consider their experience successful? Yes____ No ____

Why or why not? ______

______

  1. Do you have any concerns with your child participating in the Capital City Condors hockey program? ______

______

  1. What are your expectations of the program/goals for your child?______

______

REQUIRED HOCKEY EQUIPMENT:

-CSA approved hockey helmet with a full cage (please put player's first name on tape on forehead area of helmet)

-mouth guard

-neck guard

-hockey shoulder pads

-hockey elbow pads

-hockey pants

-jock / jill

-hockey shin pads

-hockey gloves

-skates

-hockey stick

-equipment bag

-The Condors provide: hockey jerseys and hockey socks

*Players will be issued two Condors jerseys: one black, one red. Both jerseys remain the property of the Condors unless you wish to purchase the jersey(s) for $85 each. If so, please indicate 'jersey purchase' rather than 'jersey deposit' on your second cheque memo line.

I wish to purchase: the red jersey ______the black jersey ______

Please circle player's jersey size: ADULT: XL L M S or YOUTH: XL L M S

Player's desired # ______

Please circle player's hockey sock size: S M L

Section 4

VOLUNTEERING:

Volunteers are a necessary and valued part of our hockey club. We need your participation to ensure a successful and fun year. Please indicate at least one area in which you would be able to help:

____ SHI 2015 Tournament Committee / ____ End-of-Year Banquet / ____ Fundraising
____ SHI 2015 Tournament Volunteer / ____ Golf Tournament Volunteer / ____ Golf Tournament Committee

Section 5

QUALIFIED DISCLAIMER

Parents or Guardians for participants are asked to carefully read and acknowledge the following information. This page must be signed prior to participation in the hockey program.

“Capital City Condors Hockey” refers to the organization, its directors, agents, employees, instructors and volunteers. “You” refers to both child and parent/guardian.

  • You agree that Capital City Condors Hockey is not responsible for any bodily injury, loss, or damage to personnel property suffered by the participant before, during or after the program.
  • You (parent/guardian) agree that you will remain with your child and in the arena at all times, before and after activities, assuming full responsibility for dressing and undressing your child before and after activities, and assuming full responsibility for any of your child’s personal needs (ie – bathroom trips).
  • Capital City Condors Hockey is dedicated to making sure that your child has fun. The volunteers on the ice are not professionals and have no special medical training.
  • You agree that in the event of emergency medical attention or emergency evacuation, you will not hold Capital City Condors Hockey responsible for any costs arising out of any emergency situation.
  • You agree that intentional participant behaviour that puts them or others at physical or emotional risk will result in immediate dismissal from the program at the discretion of the Capital City Condors’ directors responsible for the safety of the team.
  • You agree that expenses incurred because of dismissal from the program will be the responsibility of the participant/parent/guardian.
  • You agree that if you choose to quit the program before its conclusion, there will be no registration refund and you will immediately return the team jerseys issued to the player.
  • The safety of each individual is of the utmost importance to the Capital City Condors and all reasonable precautions are taken prior to and during the program. Capital City Condors Hockey reserves the right to alter a program at any time without compensation of participants, parents, or guardians.
  • You agree that any hockey equipment issued to an athlete that is to be used for the hockey program must be returned upon request or at the end of the season. If equipment is misplaced or lost, the player and/or parent/guardian will be responsible for reimbursing the club for the full cost of the equipment.
  • You agree that the team jerseys remains the property of the Capital City Condors and must be returned to the team upon request or at the end of the season. If the jersey(s) is misplaced, lost, or damaged beyond repair, the player and/or parent/guardian will be responsible for reimbursing the club for the full cost of replacing the jersey(s).
  • You agree that the medical background and all other information on this form is correct, and that the participant described has permission, from both parent/guardian and physician, to engage in all hockey related activities.

Player Name (Printed):______

Player Signature: ______Date: ______

Parent/Guardian Name(s): ______

(please print)

______

Parent/Guardian Signature(s): ______Date: ______

______Date: ______

Thank you for taking the time to provide us with this information. You will be contacted shortly via email by the registrar to confirm receipt of your registration package.

Sincerely,

Capital City Condors Hockey

Capital City Condors 2014 - 2015 Season

Liability Waiver

Player Name (please print): ______

I hereby give my consent for the above-mentioned player to play hockey under the auspices of the CAPITAL CITY CONDORS hereafter referred to as the C.C.C. and to abide by the rules of the C.C.C. I hereby acknowledge that the C.C.C. does not provide any medical or accident insurance, and that I am responsible for any medical, dental or similar expenses that may be incurred as a result of any accident that may occur to the above mentioned player.

I agree that I shall provide health insurance to cover any personal injury and property damage sustained by the above-noted player while participating in any activities of C.C.C hockey, the undersigned assumes all responsibility for any and all risk of damage or injury that may occur to the above mentioned player as a participant in any programs by C.C.C. Hockey, including practices, scrimmages, skills sessions, games, transportation and other activities related to the program. In consideration of such, the undersigned hereby releases and discharges the program, C.C.C. Hockey, its operators, employees, agents, supervisors, instructors, volunteers, and other players from all claims, demands,

rights or causes of action present or future, whether known or anticipated and resulting from or arising out of an incident to the above-noted player’s participation in said program.

This shall also serve as my permission to have CCC personnel act as our agent

to engage such medical and dental treatment and hospitalization as may be reasonably required in the event of illness or injury arising during or as a result of participation in the said program.

Dated at ______, this the ______of ______, ______.

(city) (day #) (month) (year)

______

Parent / Guardian Name (please print) Parent / Guardian Signature

Capital City Condors Media Release Form

2014 - 2015 Season

I consent to video footage, photos and other images of my son or daughter being taken by the Capital City Condors for a variety of public relations, communications and promotional activities, including publications, websites and advertisements, for an undefined period of time.

I understand that any video footage, photos and other images taken may be shown in a public environment, in a variety of media formats, locally, nationally, and possibly, internationally.

Players Details

Player's Surname:

______

Player's First Name:

______

The Capital City Condors can use film and still images of the above mentioned player for

use in their media and internet articles:

YES NO

[Please circle one of the above]

Parent/Guardian name (please print): ______

Signature: ______Signature Date: ______

Capital City Condors Reference Letter Introduction

2014 - 2015 Season

Dear Sir/Madam,

The following athlete, ______, has requested to join the Capital City

(please print athlete's name)

Condors hockey team. Along with completion of the registration package, the Condors also require new players over the age of 16 to present a Letter of Reference from another sports club in which the athlete has previously participated. *If the athlete has played hockey previously, the reference letter must be completed by a coaching member of that hockey club.

If you feel that you know the athlete named above well enough to accurately answer the questions below, please send the completed form to:

The Capital City Condors

146 Post Rd.

Kanata, ON, K2L 1L2

or email it to:

Be assured that your responses will be kept absolutely confidential.

Thank-you very much for your assistance in this matter.

Sincerely,

Shana Perkins, GM & Co-Founder

Capital City Condors

page 1 of 2

Capital City Condors Reference Letter

2014 - 2015 Season

**CONFIDENTIAL**

Letter of Reference for: ______, whom I observed first-hand while involved

(please print athlete's name)

in the sport of ______.

1. Please fill in the following chart with a check mark in the appropriate box using the scale of 1 – 5 (1 = very poorly or never5 = very well or always).

1 / 2 / 3 / 4 / 5
During the sports activity, did the athlete conduct himself/herself in a way that demonstrated good sportsmanship?
Did the athlete show a willingness to follow instructions?
Did the athlete show respect for the coaching staff?
Did the athlete show respect for other players?
Did the athlete, generally speaking, have a positive attitude?
Was the athlete a positive "ambassador" for the team when playing against other teams, at social events, or away at tournaments?
Was the athlete respectful of himself/herself and others in the locker room?
Did the athlete adhere to the sports activity's Code of Conduct?

2. Did the athlete have an excellent attendance record in regards to the following:

Practices? Yes / No

Fund-raising or team-building events? Yes / No

3. I have the following concerns regarding the above named player becoming a member of the Capital City Condors hockey program. (Leave blank if you have no concerns).

4. Please state the length of time you have known the athlete in a sports capacity: ______

5. I, ______, verify that I know the above-name athlete

(please print your name)

well-enough to complete this Letter of Reference on her/his behalf.

______

Signature Date

If the Condors have further questions, and you agree to be contacted in this regard, please fill in your email address or phone number below. Thank-you very much!

______

(email address or phone number, please) page 2 of 2

Capital City Condors New Player 16yrs & up Application: 2014-2015 Season Page 1 of 10