Create Your Opportunity

2017 Summer High Performance Hockey Training

Player’s Name: ______

Parent(s) Name: ______

Home Phone/Parent(s) Cell______Player Cell:______

E-mail: ______

Address: ______

City: ______Country:______Prov: ______Postal: ______

Date of Birth (dd-mm-yy): ______Height: ______Weight:______

Shirt Size: YOUTH: S M L ADULT: S M L XL

Comments/Injuries: .

.

How did you hear about Prime’? .

jjm
/ Name of 2016/17 organization:
/ Level: / Position:
Midget High Performance Program
June 26 – Aug 18/2017 (8 weeks)
90 minute sessions
Monday: 8:15-9:45am
Tuesday: 8:15-9:45am
Thursday: 8:15-9:45am
Friday: 8:15-9:45am
*Group sizes are limited & last year’s groups sold out*
Full Program - 4x/week
45+ hours of active coaching at the PerformanceCenter
Instructed boxing
Hockey specific yoga (Wednesday 7:30-8:30pm)
NEW: Sport Psychology and mental preparation sessions
Prime’ Shirt
Half Program –2x/wk (Monday & Thursday)
25+ hours of active coaching at the PerformanceCenter
Instructed boxing
Hockey specific yoga (Wednesday 7:30-8:30pm)
NEW: Sport Psychology and mental preparation sessions
Prime’ Shirt
For early bird pricing, full payment must be received on or before June 9th/2017
Post Dated Cheques or Credit Card preauthorization are required for split payments:
Cheques made out to: Prime’ Sport Performance & Kinesiology
NEW:
Credit Card Auto-withdrawals – see attached credit card authorization form

Please check the boxes that apply

ON ICE PROGRAM IS NOT INCLUDED, please see the next page for on-ice registration.

MIDGET ICE

Please check the boxes that apply (6 minimum)

Tue Jun 20, 2017 / 6:30pm – 7:30pm / Bantam/Midget Ice - Cliff McNabb Arena, 2300 Bowen
Thu Jun 22, 2017 / 4:30pm – 5:30pm / Bantam/Midget Ice - Cliff McNabb Arena, 2300 Bowen Road
Tue Jun 27, 2017 / 4:00pm – 5:00pm / Bantam/Midget Ice - Cliff McNabb Arena, 2300 Bowen Road
Thu Jun 29, 2017 / 4:30pm – 5:30pm / Bantam/Midget Ice - Cliff McNabb Arena, 2300 Bowen Road
Tue Jul 4, 2017 / 10:45am – 11:45am / Bantam/Midget Ice - Cliff McNabb Arena, 2300 Bowen Road
Thu Jul 6, 2017 / 2:30pm – 3:30pm / Bantam/Midget Ice - Cliff McNabb Arena, 2300 Bowen Road
Wed Jul 12, 2017 / 4:00pm – 5:00pm / Bantam/Midget Ice - Cliff McNabb Arena, 2300 Bowen Road
Fri Jul 14, 2017 / 5:00pm – 6:00pm / Bantam/Midget Ice - Cliff McNabb Arena, 2300 Bowen Road
Wed Jul 19, 2017 / 4:00pm – 5:00pm / Bantam/Midget Ice - Cliff McNabb Arena, 2300 Bowen Road
Fri Jul 21, 2017 / 5:00pm – 6:00pm / Bantam/Midget Ice - Cliff McNabb Arena, 2300 Bowen Road
Tue Jul 25, 2017 / 5:15pm – 6:15pm / Bantam/Midget ice - Cliff McNabb Arena, 2300 Bowen Road
Thu Jul 27, 2017 / 5:30pm – 6:45pm / Bantam/Midget - Nanaimo Ice Centre, 750 Third St
Tue Aug 1, 2017 / 5:15pm – 6:15pm / Bantam/Midget Ice - Cliff McNabb Arena, 2300 Bowen Road
Thu Aug 3, 2017 / 7:00pm – 8:15pm / Bantam/Midget Ice - Nanaimo Ice Centre, 750 Third St
Tue Aug 8, 2017 / 5:15pm – 6:15pm / Bantam/Midget Ice - Cliff McNabb Arena, 2300 Bowen Road
Thu Aug 10, 2017 / 4:00pm – 5:15pm / Bantam/Midget Ice - Cliff McNabb Arena, 2300 Bowen Road
Tue Aug 15, 2017 / 2:30pm – 3:30pm / Bantam/Midget ice - Cliff McNabb Arena, 2300 Bowen Road
Thu Aug 17, 2017 / 7:45pm – 9:00pm / Bantam/Midget Ice - Nanaimo Ice Centre, 750 Third St

Registration Information

* Registration is based on first come first serve, and class size is limited.

* To be considered ‘Enrolled’ you must:

  1. Complete the registration form
  2. Complete and sign the intake + waiver
  3. Payment processed
  4. For early bird: Full payment must be processed
  5. For monthly pricing: Week 1 cheque must be processed (made for current date) + post-dated cheques dated July 17/17(please see registration form for amount)

OR

Credit Card authorization form must be completed (last page).

All three items must be dropped off to Prime’ Sport Performance:

Suit 4 – 1970 Island Diesel Way, V9S-5W8

Office Hours:

Monday – Friday: 3:30 – 8:30pm

All programs are subject to GST and must be paid in full for early bird pricing or deposit processed upon registration. Cancellation Policy: No refunds within 10 days to the start of your camp. In the event of an accident or injury, athletes must provide a medical statement from their doctor and will be provided a full credit minus a 10% administration fee. All cancellations outside of 10 days to the start of the camp date will be provided a refund minus a 10% administration fee. PRIME’ SPORT PERFORMANCE RESERVES THE RIGHT TO CANCEL, RE-GROUP OR RESCHEDULE PLAYERS BASED ON ABILITY AND ENROLMENT. Due to the nature of group training, athletes will be expected to make their scheduled training slots. ‘Make up sessions’ will not be provided.

Thanks for choosing Prime’s High Performance Hockey Camps.

Signature (parent signature if under 18 years of age): .

Informed Consent for Participation in Physical Exercise Testing and an Active Exercise Program

Expected benefits from Testing/Exercise

The tests/exercises performed allow for the assessment/appraisal of your physical mobility, strength and cardio respiratory capacity, and through subsequent exercise to improve your overall physical fitness. The test results are used to develop a safe and sound exercise program for you. Your information is kept strictly confidential unless you consent to the release of this information.

Risks & discomforts

During testing and exercise you may experience changes in your physical condition. The changes may include abnormal blood pressure responses, fainting, irregular heart beat and heart attack. Every effort is made to minimize these occurrences. Emergency equipment, procedures and trained personnel are available to deal with these situations should they occur.

There is the slight possibility of straining a muscle or spraining a ligament during muscular fitness testing or training. In addition, you may feel muscle soreness 24 to 48 hours following testing or training sessions, commonly referred to as DOMS or “delayed onset muscle soreness”. The chance of these conditions occurring can be minimized by performing a proper warm up prior to the test or exercise sessions. If muscle soreness does occur please identify the change to the therapist/trainer so they may modify or restrict the activity to limit these symptoms if possible.

Please indicate which of the following tests/treatments you voluntarily consent to engage in;

A submaximal, graded aerobic exercise stress test and aerobic exercises

Muscular strength &/or endurance tests and strength training exercises

Flexibility tests & stretching exercises

Body composition tests

Inquiries

Questions about the procedures used to assess your physical work capacity or physical fitness status are encouraged. If you have any questions or want additional information, please ask the therapist/trainer to explain further.

Freedom of Consent

Your permission to perform the physical fitness tests and prescribed exercises is completely voluntary. You are free to stop the tests or exercises at any point, if you so desire.

PRIME’ SPORT PERFORMANCE & CONDITIONING WAIVER AND RELEASE OF LIABILITY FORM

In consideration of being allowed to participate in any way in the activities, supervised or not, Prime’ Sport Performance & Kinesiology (BN 81438 4335 BC0001) the undersigned acknowledges, appreciates, and agrees that:

1) The risk of injury from the activities involved, is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce the risk, the risk of serious injury 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 participation; and,

3) I willingly agree to comply with the stated and customary terms and conditions for participation. If however I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and,

4) I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Prime Sport Performance & Kinesiology’., their owners, coaches, and/or employees, and, if applicable, leasers of the premises, WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

5) I AGREE that this assumption of Risk, Release and Indemnity shall be EFFECTIVE AND BINDING UPON me and my heirs, executors, administrators, personal representatives, successors and assigns; and

Date:______

Name of Participant:______

Signature of Participant (or Guardian if under 19 years of age) ______

Suit 4 – 1970 Island Diesel Way

Nanaimo, B.C. Canada

250.729.5406

Recurring Payment Authorization Form

Schedule your payment to be automatically deducted from your bank account, or charged to your Visa, MasterCard, American Express or Discover Card. Just complete and sign this form to get started!

Recurring Payments Will Make Your Life Easier:

It’s convenient (saving you time and postage)

Your payment is always on time (even if you’re out of town), eliminating late charges

Here’s How Recurring Payments Work:

You authorize regularly scheduled charges to your credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.

Please complete the information below:

I (full name)authorize Prime’ Sport Performance & Kinesiology to charge my credit card indicated below for $ on the of eachmonth for payment of my bill, which has been provided to me by Prime’ Sport Performance & Kinesiology.

Billing Address______Phone#______

City, Province , Postal ______Email______

Credit Card #: ______
Visa MasterCard
Amex Discover
Cardholder Name______
Security Code (CVV Number)______
Exp. Date ______

SIGNATUREDATE

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notifyPrime’ Sport Performance & Kinesiology in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date.If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day.For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates.In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Prime’ Sport Performance & Kinesiologymay at its discretion attempt to process the charge again within 30 days, and agree to an additional $10 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of Canadian. law.I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.

Suit 4 – 1970 Island Diesel Way, V9S-5W8 | Tel: 250-729-5406 | Email: