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
07.07.2008-07.11.2008Louisville / KentuckyIceland Sports Complex$345.00
07.07.2008-07.11.2008Alexandria / VirginiaMt. Vernon Rec. Center$435.00
Full07.07.2008-07.11.2008Lake George / New YorkLake George Forum$315.00
07.14.2008-07.18.2008Richmond / VirginiaRichmond Ice Zone$460.00
07.14.2008-07.18.2008Hershey / PennsylvaniaHersheypark Arena$325.00
07.14.2008-07.18.2008Cincinnati / OhioSports Plus Arena$350.00
07.21.2008-07.25.2008Baltimore / MarylandIce World$385.00
07.21.2008-07.25.2008Dayton / OhioSouth Metro Ice $335.00
07.21.2008-07.25.2008Hampton Roads / VirginiaHampton Roads Iceplex$335.00
07.28.2008-08.01.2008York / PennsylvaniaYork City Ice Arena$325.00
Only goalie registrations accepted for York
07.28.2008-08.01.2008Wake Forest / North CarolinaFactory Ice House$415.00
07.28.2008-08.01.2008Strongsville / OhioIce Land, USA$325.00
08.04.2008-08.08.2008Alexandria / VirginiaMt. Vernon Rec. Center$435.00
Only goalie registrations accepted for Alexandria
08.04.2008-08.08.2008Columbus / IndianaHamilton Center Ice Arena$315.00
08.04.2008-08.08.2008Charleston / South CarolinaCarolina Ice Palace$345.00
08.11.2008-08.15.2008Jackson / MichiganJackson Optimist Arena$315.00
08.11.2008-08.15.2008Greensboro / North CarolinaIce House of Greensboro$395.00
08.11.2008-08.15.2008Rockville / MarylandCabin John Ice Rink$450.00
08.18.2008-08.22.2008Rochester / New YorkESL Sports Centre$325.00
08.18.2008-08.22.2008Dale City / VirginiaPrince William Ice Center$375.00
08.18.2008-08.22.2008Ithaca / New York"The Rink" Lansing$355.00
08.25.2008-08.29.2008Buffalo / New YorkLeisure Rinks$265.00
08.25.2008-08.29.2008Niagara University / New YorkDwyer Arena$250.00

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.

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