SIMONSHOCKEY.COM

I being the parent/guardian of ________________________________, hereby consent that any photographs, films, audio and video tapes for which my child posed may be used by Simons Hockey.com/Simons Recreation Center/Philadelphia Recreation Center, including newspaper, audiovisual productions, television, radio and Internet. Furthermore, I hereby consent that such interviews, photographs, films, audio and visual tapes, and the plates from which they are made be their property, and they shall have the right to duplicate, reproduce and make other uses of such photographs, films, audio and visual tapes, and plates, as they may desire free and clear of any claims whatsoever an my part.

IN WHITNESS WHEREOF I have hereunto set my hand, in The Commonwealth of Pennsylvania this

________________________(day) of___________________________(month), 2004.

Name of child_____________________________________________AGE___________________________

Address_________________________________________________________________________________

City______________________________________State____________________Zip Code_______________

If Philadelphia is your hometown, please specify the section of the city that you live in.

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Telephone Number (________)__________-________________

EMAIL___________________________________________________________________________________

Parent/Guardian Name (print)___________________________________________________

Parent/Guardian signature _(X)__________________________________________________

Please have child help write the child’s biography, as he/she would want it to appear on the SIMONSHOCKEY.COM website.

How many years playing ice hockey at Simons?________Play anywhere else?years?______________________

What does the child like the most about Simons Ice Hockey Program? _________________________________

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What position does he/she play and what do they like about that position?_______________________________

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What is the child’s favorite NHL team?__________________________________________________________

Who is the child’s favorite NHL player and why?__________________________________________________

Anything else the child would want in his/her biography? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________