Clinic Application Form
Please complete all fields:
Student's First Name*:
Student's Last Name*:
Address*:
City*:
Zip*:
Country*:
State*:
Home Phone*: xxx-xxx-xxxx
Work Phone*: xxx-xxx-xxxx
Email Address*:
Re-enter Email Address*:
Height:
Weight:
Birth Date*:      
Academy Hockey Position*: Clinics for goalies is $30.00
Present Hockey Level*:
Your Health Insurance Company*:
Your Medical History
(Please list any recent operations, current medication, injuries within the past 2 years) *
Doctor's Name*:
Sport International Clinic Locations, Tuition And Dates
Please Mark Your Choice(s)
      DateDay 1 Meet TimeLocationArenaPrice
12.26.2017-12.27.2017 3:45PM Hershey / PAHersheypark Arena$80.00
  ICE TIMES: (26) 4:30 - 6:00 PM & (27) 2:30 - 4:00 PM  
Only player registrations accepted for Hershey
12.26.2017-12.27.2017 08:15AM Rochester / NYLakeshore Hockey Arena$65.00
  ICE TIMES: 9:00 - 10:30 AM (Both Days)  
12.26.2017-12.27.2017 08:15AM Cicero / NYCicero Twin Rinks$75.00
  ICE TIMES: 9:00 - 10:30 AM (Both Days)  
12.28.2017-12.29.2017 08:15AM Altoona / PAGalactic Ice$75.00
  ICE TIMES: 9:00 - 10:30 AM (Both Days)  
Only player registrations accepted for Altoona
12.28.2017-12.29.2017 1:15PM Amherst / NYNorthtown Center at Amherst$65.00
  ICE TIMES: 2:00 - 3:30 PM (Both Days)  
12.28.2017-12.29.2017 5:15PM Reston / VASkateQuest of Reston$85.00
  ICE TIMES: 6:00 - 7:30 PM (Both Days)  
12.28.2017-12.29.2017 08:15AM Alexandria / VAMt. Vernon Rec. Center$90.00
  ICE TIMES: 9:00 - 10:30 AM (Both Days)  
Only goalie registrations accepted for Alexandria
12.29.2017-12.30.2017 08:15AM Cheektowaga / NYHoliday Twin Rinks$65.00
  ICE TIMES: 9:00 - 10:30 AM (Both Days)  
Only player registrations accepted for Cheektowaga
12.30.2017-12.31.2017 09:00AM Ebensburg / PANorth Central Rec. Center$85.00
  ICE TIMES: 9:40 - 11:10 AM (Both Days)  

Available Discounts(Discounts Do Not Apply To Goalies) - maximum of 1 discount per registration
(your discount will be automatically calculated upon check out)
* 5%
I would also like to purchase the:  DVD Professional Skill Analysis
($18.00)shipping & handling included
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
3896 Dewey Avenue, #212, Rochester, NY 14616