YOUTH APPLICATION FORM
Please complete all fields
Student's First Name*:
Student's Last Name*:
Address*:
City*:
Zip*:
Country*:
State*:
Home Phone*: xxx-xxx-xxxx
Parent's Work Phone*: xxx-xxx-xxxx
Email Address*:
Re-enter Email Address*:
Height:
Weight:
Birth Date*:      
Academy Hockey Position*:
Present Hockey Level*:
Present Hockey Organization:
Emergency Contact Name*:
Emergency Phone Number*: xxx-xxx-xxxx
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*:

Youth Camp Locations, Tuition and Dates
Please Mark Your Choice
      DateLocationArenaPrice
07.06.2009-07.10.2009Alexandria / VAMount Vernon Rec. Center$435.00
Only goalie registrations accepted for Alexandria
07.06.2009-07.10.2009Greensboro / NCIce House of Greensboro$395.00
07.06.2009-07.10.2009Louisville / KYIceland Sports Complex$345.00
07.13.2009-07.17.2009Richmond / VARichmond Ice Zone$450.00
07.13.2009-07.17.2009Hershey / PAHersheypark Arena$325.00
07.13.2009-07.17.2009Cincinnati / OHNorthland Ice Arena$350.00
07.20.2009-07.24.2009Scranton / PAScranton Ice Box$325.00
07.20.2009-07.24.2009Hampton Roads / VAHampton Roads Iceplex$335.00
07.20.2009-07.24.2009Dayton / OHSouth Metro Sports Arena$335.00
07.27.2009-07.31.2009Strongsville / OHHoover Arena/Iceland USA$325.00
07.27.2009-07.31.2009Oaks / PAOaks Center Ice$375.00
07.27.2009-07.31.2009Wake Forest / NCFactory Ice House$415.00
08.03.2009-08.07.2009Charleston / SCCarolina Ice Palace$345.00
08.03.2009-08.07.2009Columbus / INHamilton Center Ice Arena$315.00
08.03.2009-08.07.2009York / PAYork City Ice Arena$325.00
08.10.2009-08.14.2009Cicero / NYCicero Twin Rinks$295.00
08.10.2009-08.14.2009Alexandria / VAMount Vernon Rec. Center$435.00
08.10.2009-08.14.2009Rockville / MDRockville Ice Arena$450.00
Only goalie registrations accepted for Rockville
08.17.2009-08.21.2009Warwick Township / PAWarwick Ice Arena$385.00
08.17.2009-08.21.2009Rockville / MDRockville Ice Arena$450.00
08.17.2009-08.21.2009Rochester / NYESL Sports Centre$325.00
08.17.2009-08.21.2009Ithaca / NYThe Rink - Lansing$355.00
08.24.2009-08.28.2009Buffalo / NYLeisure Rinks$265.00
08.24.2009-08.28.2009Niagara University / NYDwyer Arena$250.00
08.24.2009-08.28.2009Saratoga Springs / NYSaratoga Springs Ice Rink$295.00

Available Discounts - maximum of 1 discount per registration
(your discount will be automatically calculated upon check out)
n/a
n/a
*
*
* Name of New Student for Referral Discount:
I would also like to purchase the:  DVD Professional Skill Analysis
($15.00)
Please register my son/daughter for the following Lunch Program:  "No Meals"
 "Youth Meal" Lunch Program
($35.00)
 "Big Kid Meal" Lunch Program
($46.00)
How did you hear about the Sport International Hockey Academy?





 
Additional Sport International Offers
(Please Send Me Additional Information)
#
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 me 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. I fully understand the above mentioned details regarding The Sport International Hockey Academy waiver terms and I also agree and understand that all tuition payments are Nonrefundable.

Head Office (800) 724-6658 · Fax# (585) 865-1802 · The Sport International Hockey Academy
3800 Dewey Avenue, #212, Rochester, NY 14616