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:____________________________

Revolution Ice Center, July 20 - 24

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

Please Register My Son/Daughter For The following Extras;

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

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).

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: ____________________