Application for Participation Applying as a*2000-20022003-2004Name*Birthdate* Gender*MaleFemalePosition Forward Defense Goalie Last Team Played ForHeightWeightShootsGrade in SchoolGPA/AverageFavourite SubjectFuture Career Plans (Other Than Hockey), if any, at this timeMailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home Phone*Cell PhoneEmail* Father's Full NameMother's Full NameAuthorized by Parent or Guardian* I / we hereby release College Hockey Atlantic Incorporated, its officers, employees and agents from all liability, claims, causes of actions of any kind whatsoever, in respect of damages that I and/or my child may suffer as a consequence of my child sustaining personal injury, death or property damage or loss while participating in programs and activities of the College Hockey Atlantic Combine, and I / we do hereby agree to indemnify and hold harmless College Hockey Atlantic Incorporated, its officers, employees, or agents from any and all claims, demands, and causes of actions of any kind whatsoever, including those involving negligence on the part of College Hockey Atlantic Incorporated, or any of its officers, employees or agents that may be made or initiated by, or on behalf of myself or my child, arising out of, or connected with, my said child’s preparation for, or participation in, any of College Hocley Atlantic Incorporated programs or activities, now or at anytime in the future. I further understand that by submitting this application form, that said application is subject to review by the Committee overseeing the College Hockey Atlantic Combine, and they can make a decision regarding my child's participation in the event based on any criteria that they so desire, in their sole discretion without any explanation. Space in the event is limited, and players will be evaluated to ensure that the quality of play will be consistent, and at the highest level possible. Because our guest scouts and recruiters will be looking for student-athletes to represent their programs and institutions in the future, it is acknowledged and agreed that other factors, besides "hockey" will also be used to evaluate applicants, and may include discussions with independent scouts, the review of scouting reports, past coaches, academic institutions and members of the general public, all of which is acknowledged and agreed.It is acknowledged that the event, as of today’s date is tentatively scheduled for the place and times indicated, but as the actual date comes closer, it is acknowledged and agreed that some aspects of the event (including dates and times, and local arena locations) may change with short notice, which will be provided through regular updates on the official website for the event, and may continue to be amended right up until the specific event.Players should expect to receive an email response to their application within 10 business days of submission. It is understood and agreed that should an application not be approved by the Committee, a refund will be issued, less a $50 processing fee.It is acknowledged and agreed that once accepted into the Combine Event, there will be no refunds for any reason. I am paying by*Online Via Credit CardChequeApplication Price: $ 575.00 CAD HST 15% Price: $ 0.00 CAD Total $ 0.00 CAD Credit Card American ExpressMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Application Price: $661.25 including HSTApplication Price: $575.00 + HST Make cheque out to College Hockey Atlantic Inc. for $661.25 and send to College Hockey Atlantic Incorporated Park Central, Suite 12-A 109 Ilsley Avenue Dartmouth, NS CANADA B3B 1S8PhoneThis field is for validation purposes and should be left unchanged.