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2018-2019 NCCP High Performance 1

Personal Information

First Name *  
Last Name *  
Date of Birth *    
Format: yyyy-mm-dd

Address Information

Street Address *  
City/Town *  
Country *
Province *    
Postal Code *  

Contact Information

Phone Number *    
Format: 555-555-5555
Email *    
MHA/League *  
Role*  
T-Shirt Size*  

Team Experience (Team, Category)

Projected 2018-2019 Team
2017-2018 Team
2016-2017 Team
2015-2016 Team
NCCP #
Certification Level
HCR #
Qualifications Held

Medical Information

Care Card Number *  
Family Doctor *  
Doctor Phone *    
Format: 555-555-5555
Medical Insurance Number
 
Group Number
 
Certificate Number
 

Hospitalized in the last year?
 
Presently injured?
 
Injuries requiring medical attention?
 
Wears dental appliance?
 
Ill longer than one week in the past year?
 
Wears contact lenses?
 
Allergies to medication, etc?
 
Asthmatic?
 
Trouble breathing during exercise?
 
Diabetic?
 
Fainting during exercise?
 
Epileptic?
 
Difficulty hearing?
 
Heart Condition?
 
Interfering health problems?
 
Learning disability?
 
Medic alert bracelet?
 
Wears glasses?
 
History of concussions?
 
Taking medications?
 
Surgery in the past year?
 
If you selected YES to any of the above medical conditions that may affect your ability to fully participate in the camp, please specify below.

By clicking the PayPal link (below) you agree to the following:

As individual of age of majority / parent / legal guardian (the “Applicant”), I have completed the above information and agree that, provided an attempt has been made to contact the Applicant and the Emergency Contact, I authorize anyone acting on behalf of the British Columbia Amateur Hockey Association to seek medical and / or dental advice or treatment for my son / daughter / self as recommended by a licenced medical practitioner if medical and / or dental treatment is required or suspected to be required as a result of illness, injury or unknown malady. 

I further authorize that, at the direction any Program Leader acting on behalf of the British Columbia Amateur Hockey Association, my son / daughter / self may be sent home at my expense in the event of a medical, dental and / or behavioural situation.    

Furthermore, for good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I grant to the British Columbia Amateur Hockey Association (the “Producer”) and to its administrators, successors, assigns, servants, agents, insurers, officers, directors and other successors in interest all rights in and to my / my child’s appearance, name, and / or voice and the results and proceeds thereof in connection with my or my child’s participation in the Producer’s programs and events. 

I hereby authorize the Producer to photograph and record on film, tape, or otherwise my / my child’s participation in the Producer’s programs or events (the “Recording”).  I further authorize the Producer to edit the Recording at its discretion; to include the Recording with the performances of others; to add to the Recording sound effects, special effects and music; and  to licence others to use the Recording. 

I further authorize the Producer to use my / my child’s name, likeness, voice, biographic information and other information in connection with the Recording. 

In addition, I hereby release, remise and forever discharge the Producer, its administrators, successors, assigns, servants, agents, insurers, officers, directors and other successors in interest from any liability in connection with the production and / or use of any Recordings. 

Review the BC Hockey Privacy Policy Here


Seminar Fee: $1,900.00
GST: $95.00
Total: $1,995.00

Application Fee: Please be aware that there is a $50.00 non-refundable application fee due immediately. Should you be accepted into the seminar, this will be adjusted from your final invoice.

Application Deadline: June 25, 2018. Please note: registration fee includes resources, accommodations, meals and evaluation.

Refund Policy: Please refer to the BC Hockey Handbook, Section 2.02 F.

Applicant Review: Applicants will be reviewed on a monthly basis and selected based partially on first come, first serve basis should they meet the eligibility requirements.


Coaching/Education Resume:  

MHA Letter of Reference:  


All applications will be reviewed the by Coach Committee Review Team. Successful applicants will be contacted by June 1, 2018 and payments will be taken at that time.


ABOUT US
BC Hockey is a non-profit organization and member branch of Hockey Canada in charge of governing amateur hockey at all levels in British Columbia and the Yukon Territory.

Approximately 150 minor hockey associations, 55,000 players, 4,500 referees, 20,000 official volunteers and countless others make our great game possible here in Pacific Canada.

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