City of Philadelphia

Department of Recreation

Simons Recreation Center

Walnut Lane & Woolston Ave.

(215)-685-3551

SIMONS INSTRUCTIONAL HOCKEY

CHILD’S NAME:__________________________________________Age________Gender______

ADDRESS: ______________________________________________________________Zip_____

School Child Attends:__________________________________________________Grade_______

Parent or Guardian’s Full Name’s_____________________________________________________

Home Phone:_(_____)-_______-_______________Work/Cell-_(_____)-________-_____________

Emergency Contact:___________________________________PHONE_(____ )-_______-_______

Any Medical problems or Concerns we should be aware of about your child? Circle YES or NO

Please_Explain______________________________________________________________________________________________________________________________________________________________________________________________________________________________

I hereby authorize and give permission for my child (listed above), to participate fully in the instructional Hockey program at Simon Recreation Center. I Further authorize any employee of the Philadelphia Department of Recreation to seek in the event of a serious medical emergency, proper medical attention, as my delegate because I or the emergency contact listed above can not be contacted by telephone.

(Print)__________________________ X__________________________ _____________

Parent or Legal Guardian’s Full Name Signature Date

Amount Due: $85.00 Amount Paid $_________________ Check # _________Cash $________

Make Checks Payable to: Simons Advisory Council

EQUIPTMENT CONSIGNMENT

My child does_____ or does not ______ need equipment supplied by Simons Recreation Center.

I agree to return ALL the equipment at the completion of the program to Simons Recreation Center

TYPE	SIZE	BRAND	MODEL
SKATES
HELMET
SHOULDER PADS
ELBOW PADS
HOCKEY GLOVES
HOCKEY PANTS
SHINPADS
NECK GUARD
SOX / SUSPENDERS
HOCKEY BAG
JERSEY

MAKE ANY NOTE ON BACK OF FORM