REGISTRATION FORM
Print out this form and mail it with the fee to:
DC SELECTS  |  PO Box 7243  |  Gaithersburg, MD 20898-7243

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Participant Name

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Address

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City - State - Zip

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Phone

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E-mail Address (print clearly)

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Last Year's Team & Level

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Position                             Ht. / Wt.                           Date of Birth

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Emergency Contact Name & Phone

 

-- SESSION SELECTION --

 
2002     2001
           
2000     1999
           
CASH        
CHECK PAYABLE TO NBNHS        
VISA \ MC #     Exp  

Register by birth year

In consideration of this tryout fee and and participation in the DC SELECTS Tryout, we do hereby forever release and discharge DC SELECTS, NBNHS, Dynamic Hockey, Montgomery Youth Hockey Association, Rockville Ice Arena and Cabin John Ice Rink, their directors, agents, employees and any person or corporation connected herewith from all manner of action, injury, damages, costs, claims or demands which we shall or may hereafter have, suffer or receive by reason of such participation in the program.  The release shall be binding on our heirs, assigns, executors and administrators. It is further agreed that DC SELECTS, NBNHS, Dynamic Hockey, Montgomery Youth Hockey Association, Rockville Ice Arena and Cabin John Ice Rink, do not and shall not be considered to guarantee or warrant such equipment as may be used.

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Signature of Parent / Legal Guardian                               Date



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