THE SPORT INTERNATIONAL HOCKEY ACADEMY
2012 YOUTH CAMP REGISTRATION FORM
 Please Complete all Information. Please Print.
 Student's Name:___________________________________________
 Address:_________________________________________________
 City/State:____________________ Zip:_______________
 Home Phone:_______________ Parent’s Work Phone:________________

 Ht.:__________ Wt.:___________ Birth Date:________________

 *E-mail Address (for confirmation letter/receipt):___________________________________          

Academy Hockey Position:     Forward     Defense     Goalie
Present Hockey Level:     Travel     House     Beginner
Present Hockey Organization:__________________________________
Emergency Contact Name:________________________Phone Number:__________
Family Health Insurance Company:__________________________
Student’s Medical History (Please list any recent operations,
current Medication, Injuries within the past 2 years.) ___________________________________________________________________________________

Doctor's Name:____________________________

Hockey Jersey Size Please Circle Choices

BOY'S: Large

MEN'S: Sm.   Med.    Lg.     XL     XXL

 

Mail Application To:   

S.I.H.A.
3896 Dewey Ave, # 212
Rochester, NY 14616
Phone: 1-800-724-6658
Fax: (585) 865-1802


    Year 2012 Sport International Locations, Tuition and Dates
Please Mark Your Choice(s)

      City/State
Price
Arena, Date
O   Canton, OH
$300.00
Center Ice Sports Complex , June 11 - 15
O   Hillsborough,NC
$405.00
Triangle Sportsplex , June 11 - 15
O   Wilmington, NC
$360.00
Wilmington Ice House, June 11 - 15
O   Fishers, IN
$375.00
The Forum at Fishers, June 18 - 22
O   Greensboro , NC
$400.00
Ice House of Greensboro, June 18 - 22
O   Reisterstown, MD
$410.00
Reisterstown Ice Arena , June 18 - 22
O   Nashville, TN
$380.00
Centennial Sportsplex, June 25 - 29
O   Rockville, MD
$475.00
Rockville Ice Arena, June 25 - 29
O   Alexandria, VA
$465.00
Mt. Vernon Rec. Center, June 25 - 29
O   Raleigh, NC
$405.00
The Raleigh Iceplex, July 9 - 13
O   Cincinnati, OH
$335.00
Northland Ice Arena, July 9 - 13
O   Hershey, PA
$345.00
Hersheypark Arena, July 9 - 13
O   Dayton, OH
$355.00
South Metro Sports, July 16 - 20
O   Hampton Roads,VA
$350.00
Hampton Roads Iceplex , July 16 - 20
O   Niagara Univ., NY
$270.00
Dwyer Arena , July 16 - 20
O   Binghamton, NY
$290.00
Chenango Ice Rink , July 23 - 27
O   Charleston, SC
$360.00
Carolina Ice Palace, July 23 - 27
O   Rockville, MD
$475.00
Rockville Ice Arena, July 23 - 27
O   Buffalo, NY
$275.00
Leisure Rinks, July 30 - Aug. 3
O   Richmond, VA
$400.00
Richmond Ice Zone, July 30 - Aug. 3
O   Alexandria, VA
$465.00
Mt.Vernon Rec. Center, July 30 - Aug. 3
O   Cicero, NY
$300.00
Cicero Twin Rinks, Aug. 6 - 10
O   Clifton Park , NY
$295.00
Clifton Park Ice Arena , Aug. 6 - 10
O   Rockville, MD
$475.00
Rockville Ice Arena, Aug. 6 - 10
O   Jamestown, NY
$325.00
Jamestown Savings Bank Arena, Aug. 13 - 17
O   Rockville, MD
$475.00
Rockville Ice Arena, Aug. 13 - 17 (Elite Camp)
O   Oaks, PA
$400.00
Oaks Center Ice Arena, Aug. 13 - 17
O   Ithaca, NY
$360.00
"The Rink" (Lansing) , Aug. 20 - 24
O   Buffalo, NY
$275.00
Leisure Rinks, Aug. 20 - 24
O   Pittston, PA
$345.00

Revolution Ice Center, July 20 - 24

O   Binghamton, NY
$290.00
Chenango Ice Rink, Aug. 27 - 31
O   Niagara Univ. , NY
$270.00
Dwyer Arena , Aug. 27 - 31

Camp Tuition, Is Based On Ice Prices, In Each Individual City!

     Available Discounts
(Please Mark Your Discount for Credit -
One Discount Max. Per Application)

O   7% Very Early Bird Discount (Full/One Time) payment before December 31/11

O   5% Early Bird Discount (Full/One Time) payment before March 15/2012
O   5% Family Discount (2 or more family members-must be faxed/mailed together)
O   7% Group Discount (7 or more players in a group-must be faxed/mailed together) O   10% Multiple Week Discount (2 or more weeks chosen for our 2012 Summer Tour)

Please Register My Son/Daughter For The following Extras;

O   DVD Professional Skill Analysis (Individual Analysis) ($15.00)

O   DVD Game-Tape Analysis (Group Analysis) ($15.00)
O   "Youth Meal" - Lunch Program ($37.00)
O   Rockville "Youth Meal" - Lunch Program ($47.00) - For Rockville, MD Students Only
O   "Big Kid Meal" - Lunch Program ($48.00)

O   Rockville "Big Kid Meal" - Lunch Program ($58.00) - For Rockville, MD Students Only

**NOTE: (Rockville Students Only) - A $10.00 Catering Surcharge will be added to your lunch program (Youth or Big Kid Meal).

How did you hear about the Sport International Hockey Academy?
O  Returning    O  Recommendation   O  Amer. Hockey Magazine
O  Rink Display   O  Mail    O  Internet   O  SIHA Regional Director  
Additional Brochure Request:
O   Free Summer Camp Brochures For Friends #________
Please Indicate Your Method and Amount of
    Payment For Our 2012 Instructional Tour
O  Check/Money Order:    $____________________

O  Visa   O  Master Card   O  Discover:    $____________________
(50% Non-Refundable Deposit Minimum)
Card # __ __ __ __ / __ __ __ __ / __ __ __ __ / __ __ __ __ Exp. Date: __ __ / __ __

Credit Card Holders Name: __________________________________________________

Credit Card Holder's Address & Zip Code:_______________________________________
  Authorized Signature: _________________________________________

REFUND POLICY: Refunds will not be considered regarding any issues, within 2 weeks prior to your chosen week (Cr. Only).

Waiver Claim: Acknowledging that ice hockey is a contact sport, I agree that Sport International, Inc. its agents, servants and employees shall not be liable to me for any injury or damage resulting directly or indirectly from my participation in ice skating and ice hockey, whether incurred on the ice or otherwise in or about the buildings. I further agree that I discharge Sport International, Inc. its agents, servants and employees from all actions, claims and demands I may have for any injury or damage. I understand that my said agreements, release and discharge shall bind by heirs, legal representatives and assigns and shall insure to the benefit to Sport International, Inc., its agents, servants and employees and their successors and assigns. It is further agreed that Sport International, Inc. does not and shall not be considered to guarantee/warrant such equipment as may be used in the conducting of said program. I also give my consent to the Sport International Hockey Academy to treat my son/daughter at their discretion, in case of any emergency incident that may arise throughout the instructional week. Sport International, Inc., reserves the right to use any pictures & videos taken during the program for research, instruction and/or advertising.

Parent/Guardian Signature (Required):

X___________________________________________ Date: ____________________

Head Office: (800) 724-6658 • Fax#: (585) 865-1802 • The Sport International Hockey Academy
3896 Dewey Avenue, #212, Rochester, NY 14616