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2000 Hewitt Ave. + Everett, WA 98201

2018 Spring ECIR Goalie Clinic




Entire Program Fees Due with Application

Please make checks payable to - CCIR


Circle One:    Cash       Check       Money Order     Visa      Master Card


Credit Card #:                                    Exp. Date:                                            





Players Name:                                                                                                   Address:       


Cardholder Signature:                                                                                       Please return completed and Signed Application with full payment to:

Everett Community Ice Rink


City:                                     State:                




“ECIR Goalie Clinic”

2000 Hewitt Ave. Suite 200


Birth Date:                                 Age:                    


Parents / Guardian           _                                  _                                           Home Phone:              Work Phone:                                                                E-Mail:                                                                      USA Hockey Number                                                                                                                         

*Please bring in USA hockey registration


Everett, WA 98201



I/we the parents of                                                   _             _ -do hereby give my/our consent to any authorized physician to perform such medical services as may be necessary because of participation of my/our son or daughter in the Everett Community Ice Rink activities. I/we do further hereby release, absolve, in- demnify and hold harmless the ice arena, the officers, board members, coaches, supervisors and any authorized physician, any or all of them for any injuries in- curred either accidental or by the negligence of their selves or others while partici- pating in said program. I/we hereby waive all claims against the aforementioned parties or any other persons appointed by then or any authorized physician. I/we understand that the term "authorized" physician means not only our own physician listed below, but any other licensed, practicing physician who is called to perform the required medical services.


I have read and understand the above statement:                                               __ Date:        


Registration accepted on a first received basis.

No  refunds, unless due to medical emergency


2000 Hewitt Ave. Suite 200

For Office Use Only

Payment Amount:              CA:                CH: #                    

Charge: VI / MC        Initial                       Date:                    Trans#:                      

Everett, WA 98201

(425) 322-2653

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