Submit on line below (Preferred method)

Mail to:

The ELLIS EDGE

144 French Village Rd.

Rothesay, NB, Canada

E2S 1A9

Fax to: 506-849-9579

If faxing, send an email to make sure I received it.

Ottawa Masters Camp Registration Form

Name

Address

City

Province / State

Post code/ zip

Home phone

Cell

Work

Age

Club

Sex

500 ST Time

Camp: Check the camp you wish to register for.

A $100 non refundable deposit is required to be officially registered for camp. There aere a limited number of skaters in each camp. * Please make cheque payable to Ellis Edge.

Athlete Waiver and Release

Please ensure you complete all sections of this form before submitting including Registration, Waiver, and Medical Information

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Participants Name

Dated:

Medical Information and Permission to Treat

This information will be maintained in a confidential file by the Ellis Edge Inc. It will only be shared with camp representatives who need to know this information in order to do their jobs properly. If there is additional information that you consider pertinent to the participant's well-being at the Camp, please add it to the form or send it separately.

Month

Day

Year

Name

Date of Birth:

Month

Day

Year

Full Address

Street number, Street name, PO Box, City, Province or State, Postal Code

Home Phone

Cell

Emergency contact name (s)

Emergency phone numbers

Doctor's name

Doctor's number

Medicare number

Other insurance:

Policy number

Allergies:

Drug Allergy

Specify

Insect Allergy

Specify

Other Allergy

Specify

Food Allergy

Specify

The participant carries an ANA kit or EPI pen,

and knows how to use it

Medical Conditions / Disabilities:

Diabetes

Epilepsy

Asthsma

Medications and frequency

ADD

Medication

Describe any other Medical Conditions /Disabilities / Medications

Camp authorities should be concerned if they see the following signs or symptoms:

Special needs during the camp:

Other concerns:

Dietary Restrictions:

Dated

Month

Day

Year

Signature

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Participant's signature

In consideration of being permitted to participate in the Ellis Edge Summer Speed Skating Camp located in Ottawa, ON at the Carleton Ice House, Carleton University, August 6-10, and to use the recreation facilities of the City of Ottawa, Carleton University, Carleton Ice House, and other facilities  or venues that may be used during the camp, including the ice surface, grounds and related activities, the undersigned participant, and the parent or legal guardian if the participant is a minor, (hereinafter “Releasor(s)”):

1.	Agree to inspect all above listed facilities and Ellis Edge equipment to be used prior to use or participation. If above facilities or equipment is found to unsafe by the Releasor(s) the Releasor(s) shall immediately notify Ellis Edge of the unsafe condition and refuse to use the unsafe facility or equipment. If any athletic/sports program or activity is found to be unsafe by the Releasor(s), the Releasor(s) shall immediately notify the program or activities coach or supervisor of the unsafe condition and refuse to participate in the program or activity. It is the duty of the Releasor(s) to provide all personal equipment and protective devices and to maintain such equipment and items in proper condition.

2.	Acknowledgement and fully understand that the athletics/sports programs or activities to be engaged in involve risk of serious injury, including permanent disability or death, and severe social and economic loses that may result not only from their actions, inactions or negligence, but also the action, inaction or negligence of others, the rules of play, or the condition of the facilities or of any equipment used. Further, there may be other risks not known to or reasonably foreseeable at the time of use or participation.

3.	Knowing of the foregoing risks, Releasor(s) agree to assume those risks and accept personal responsibility for all damages following such injury, permanent disability or death.

4.	Release, waive, discharge, and covenant not to the Carleton University Ice House, Carleton University,  Ellis Edge Inc., any affiliated clubs, their administrator, directors, agent, coaches, or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, the owners and lessees of premises used to conduct the program or activity, (all of which are hereinafter referred to as “Releasees”). From any and all liability to the Releasor(s), their heirs and assigns for any and all claims, property damage, caused or alleged to be caused in whole or in part by the negligence of the releasors.

I have read the above release of liability. I understand that I/we give up substantial rights by signing and I/we sign voluntarily.