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*:	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    199419951996199719981999200020012002200320042005200620072008
Academy Hockey Position*:	Please select: Forward Defense Goalie Clinics for goalies is $30.00
Present Hockey Level*:	Please select: Travel House Beginner
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)

There are no clinics available to register for at this time.

Available Discounts - maximum of 1 discount per registration
(your discount will be automatically calculated upon check out)

	* 5% Family Discount (2 or more family members)
	5% Returning Student Discount

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)

Brochures #

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. I have read the Waiver Claim and agree to the conditions described.

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