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John Roderick's Power Skating, Skills & Conditioning Clinics
Summer Clinics 2021
O’Brien Rink, 55 Locust St.
Woburn, MA 01801
Please Check All That Apply:
❑ Monday, June 7th through Monday, August 9th (10 Monday Nights)
L.T.P., Mite/U8, Squirt/U10, Peewee/U13 Boys and Girls (except high school age)
Skills, Powerskating, Conditioning Clinic and Goalie Instruction with Chris Czarnota
6:00pm-7:30pm: On Ice Skills, Powerskating and Conditioning
$400 per skater (15 hours of on ice instruction)
❑ Monday, June 7th through Monday, August 9th (10 Monday Nights)
High School Level Boys and Girls (U14 - U19)
Skills, Powerskating, Conditioning Clinic/Goalie Instruction with Chris Czarnota
7:30pm-9:00pm: On Ice Skills, Powerskating and Conditioning
$400 per skater (15 hours of on ice instruction)
❑ Monday, August 23rd through Thursday, August 26th (week long clinic)
L.T.P., Mite/U8, Squirt/U10, Peewee/U13 Boys and Girls
6:00pm-7:30pm: On Ice Skills and Powerskating/Goalie Instruction with Chris Czarnota
$150 per skater (6 hours of on ice instruction)
❑ Monday, August 23rd through Thursday, August 26th (week long clinic)
High School Level Boys and Girls (U14 - U19)
Dryland, Skills and Powerskating Clinic/Goalie Instruction with Chris Czarnota
6:00pm-7:00pm Dryland Training (adjacent soccer fields)
7:30pm-9:00pm: On Ice Skills, Powerskating and Conditioning Clinic
$200 per skater (4 hours of dryland & 6 hours of on ice instruction)
❑ Monday, August 31st through Thursday, September 3rd (week long clinic)
All Levels U8-U19 Boys and Girls (must have 1 year of Learn to Play)
6:00pm-8:00pm: On Ice Skills and Powerskating/Goalie Instruction with Chris Czarnota
$200 per skater (6 hours of on ice instruction)
Please Fill Out All Information Below:
Name of Child: ___________________________________________________________
Date of Birth: ____/____/_______ Age: __________ ❑ Male ❑ Female ❑ Nonbinary
Current Youth Hockey/Select/Elite Program: _____________________________________________
Youth Hockey/Select/Club Team Level (please check one): ❑Learn to Play Hockey/City League/Tri-City/U6Girls ❑Mite/U8Girls ❑Squirt/U10Girls ❑Peewee/U12Girls ❑Bantam/U14Girls ❑U16 Boys/Girls ❑U18 Boys/Girls
Parent/Guardian Name: ___________________________________________________
Phone: _______________________ Email: ___________________________________
DISCOUNTS: If you sign up for both clinics (4 days both weeks), there is a $25 discount per skater. If you sign up more than one sibling, there is a $25 discount for each sibling after the 1st (i.e. child #2 $25 off, child #3 $25 off, etc.). No multi-clinic or sibling discounts if your child(ren) doesn’t attend all 4 days.
*Please be advised that credits/refunds may only be issued 48 hours prior to the first day/night this clinic begins. Staffing is in conjunction with an exact amount of kids. If your child has a medical emergency after the start date, please forward a doctors note to John Roderick. If there are any other questions or concerns, please contact John at: john@roderickhockeyskills.com. Checks must accompany this application in order to reserve a spot for your child(ren).
❑ I have read and understand the credit/refund policy.
Venmo payment to: @John-Roderick-1 or
Mail this registration, waiver form and check made out to:
John Roderick, 3 Abbott Court Woburn, MA 01801
Summer 2021 Ice Hockey Clinic Wavier of Liability
I agree that I shall provide health insurance to cover any personal injury and property damage sustained by the camper while participating in any activities of or while on the premises leased or otherwise under the control of John Roderick’s School Break Clinics & Camps. The undersigned assumes all responsibility for any and all risk of damage or injury that may occur to the above named player as a participant in John Roderick’s School Break Clinics & Camps, including practices, scrimmages, skills sessions, clinics, games, and other activities related to the program. Additionally, the undersigned hereby releases and discharges the program, John Roderick, its operators, employees, agents, supervisors, instructors and other players from all claims, demands, rights or causes of action present or future, whether known or anticipated and resulting from or arising out of an incident to the undersigned participation in said program. This is also my permission to have my child admitted and attended to for medical and dental treatment, in case of sickness or injury, that all physicals and inoculations are up to date. John Roderick’s School Break Clinics has a zero tolerance policy with respect to uncontrollable behavior, bullying, hazing. Any skater found to have committed these acts will be immediately dismissed from the program and will forfeit all amounts paid. By signing this release and by being enrolled in this program you assent to the enforcement of this. Dates and times are subject to change due to weather and rink malfunctions. I understand that this document is intended to be as broad and inclusive as permitted by the laws of the state in which the camp is taking place and agree that if any portion of this agreement is invalid, the remainder shall continue in full legal force and effect. I further agree that any legal proceedings related to this waiver shall take place in the Boston, Commonwealth of Massachusetts.
Parent/Guardian Name: ________________________________________________________
Signature of Parent/Legal Guardian: _____________________________________________
Date: _________________________________________________________________________
Note: This release must be signed prior to the participation in the Program
