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| LOANER |
EQUIPMENT |
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| Date _______________________ |
Date________________________ |
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| Receive equipment from:____________________ |
Return equipment to: _______________________ |
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OUT |
IN |
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Value of, if not returned: |
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Helmet______________________ |
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$ 50.00 |
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Shoulder Pads______________________ |
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$ 35.00 |
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Elbow Pads _____________________ |
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$ 25.00 |
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Pants _____________________ |
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$ 45.00 |
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Shine Pads _____________________ |
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$ 35.00 |
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Jersey & Socks _____________________ |
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$ 25.00 |
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Stick____________ |
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$ 15.00 |
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| Loss or theft of equipment is the responsibility of the renter. |
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| You assume total responsibility of the loaner equipment from the moment it is received. |
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| Do not leave gear unattended in public areas for extended periods of time without locking them away. |
| In the case of equipment not returned, under whatever circumstances, |
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| the renter will be charged the purchase cost of the equipment. |
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| NAME |
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BIRTHDAY |
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POSITION |
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| PARENT / LEGAL GUARDIAN NAME |
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| ADDRESS |
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CITY |
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STATE |
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| HOME PHONE |
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WORK |
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CELL |
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| E - MAIL |
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| Credit card number ______________________________________ exp ______________ |
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 or  accepted |
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Please Read |
Carefully! |
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| WAIVER AND RELEASE OF LIABILITY |
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| ICEOPLEX, as well as any employees will not be held liable for any injuries or from any equipment |
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| defect. Participant release ICEOPLEX of any liability regarding injury or death. |
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| I have read the above waiver and release and understand that I have given up my sustantial rights by signing it and |
| sign it voluntarily. I also agree to abide by all rules of the ICEOPLEX youth hockey program. |
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| Parent's Name_______________________________________ |
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| Parent’s Signature____________________________________ |
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| Luc Beausoleil |
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| Hockey Director |
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| luc@iceoplex.com |
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| 805-520-7465 ext 18 |
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