THE SPORT INTERNATIONAL HOCKEY ACADEMY
2019 SUMMER 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:____________________________

Hockey Jersey Size Please Circle Choices

BOY'S: Large

MEN'S: Sm.   Med.    Lg.     XL     XXL

Mail Application To:   

S.I.H.A.
3896 Dewey Ave, # 212
Rochester, NY 14616
Phone: 1-800-724-6658
Fax: (585) 865-1802


    Year 2019 Sport International Locations, Tuition and Dates
Please Mark Your Choice(s)

      City/State
Price
Arena, Date
O   Canton, OH
$200.00
Center Ice Sports Complex , June 10 - 14
O   Hillsborough,NC
$425.00
Orange County Sportsplex , June 17 - 21
O   Canton, OH
$225.00
Center Ice Sports Complex, June 17 - 21
O   Cincinnati, OH
$350.00
Sports Plus Arena, June 17 - 21
O     Alexandria , VA
$515.00
Mt. Vernon Rec. Center, June 24 - 28
O   Rockville, MD
$560.00
Rockville Ice Arena , June 24 - 28
O   Altoona, PA
$315.00
Galactic Ice, June 24 - 28
O   Hershey, PA
$350.00
Hersheypark Arena, July 8 - 12
O   Erie, PA
$325.00
Erie Bank Sports Park, July 8 - 12
O   Cicero, NY
$335.00
Cicero Twin Rinks, July 8 - 12
O   Fairport, NY
$320.00
Rochester Ice Center, July 15 - 19
O   Ebensburg, PA
$330.00
North Central Rec. Center, July 15 - 19
O   Lockport, NY
$310.00
Cornerstone Ice Arena, July 15 - 19
O   Rockville, MD
$560.00
Rockville Ice Arena , July 22 - 26
O   Reisterstown, MD
$425.00
Reisterstown Sportsplex , July 22 - 26
O   Buffalo, NY
$295.00
Leisure Rinks , July 22 - 26
O   Reston, VA
$490.00
SkateQuest of Reston, July 29 - Aug. 2
O   Waldorf, MD
$400.00
Capital Clubhouse Rec. Center, July 29 - Aug. 2
O     Altoona, PA
$315.00
Galactic Ice, July 29 - Aug. 2
O   Alexandria, VA
$515.00
Mt. Vernon Rec. Center, August 5 - 9
O   York, PA
$325.00
York Ice Arena, August 5 - 9
O   Ebensburg, PA
$330.00
North Central Rec. Center, August 5 - 9
O   Rochester , NY
$295.00
Lakeshore Hockey Arena , August 12 - 16
O   Rockville, MD
$560.00
Rockville Ice Arena, August 12 - 16
O   Ithaca, NY
$395.00
"The Rink" - Lansing, August 12 - 16
O   Buffalo, NY
$295.00
Leisure Rinks, August 19 - 23
O     Hooksett, NH
$385.00
Tri-Town Ice Arena, August 19 - 23
O   Niagara Univ., NY
$315.00
Dwyer Arena , August 26 - 30

Camp Tuition, Is Based On Ice Prices, In Each Individual City!

     Available Discounts
(Please Mark Your Discount for Credit -
One Discount Max. Per Application)

O   7% Very Early Bird Discount (Full/One Time) payment before December 31/18

O   5% Early Bird Discount (Full/One Time) payment before March 15/2019
O   5% Family Discount (2 or more family members-must be faxed/mailed together)
O   7% Group Discount (7 or more players in a group-must be faxed/mailed together) O   10% Multiple Week Discount (2 or more weeks chosen for our 2019 Summer Tour)

Please Register My Son/Daughter For The following Extras;

O   Flash Drive Professional Skill Video Analysis (Individual Analysis) ($20.00)

O   "Youth Meal" - Lunch Program ($40.00)

O   "Big Kid Meal" - Lunch Program ($50.00)

**NOTE: (Rockville, Rochester, Fairport & Niagara Univ. Students Only) - A $10.00 Catering Surcharge will be added to your lunch program (Youth or Big Kid Meal).

How did you hear about the Sport International Hockey Academy?
O  Returning    O  Recommendation   O  USA Hockey Magazine
O  Rink Display   O  Mail    O  Internet   O  SIHA Regional Director  
Additional Brochure Request:
O   Free Summer Camp Brochures For Friends #________
Please Indicate Your Method and Amount of
    Payment For Our 2019 Instructional Tour
O  Check/Money Order:    $____________________

O  Visa   O  Master Card   O  Discover:    $____________________
(50% Non-Refundable Deposit Minimum)
Card # __ __ __ __ / __ __ __ __ / __ __ __ __ / __ __ __ __ Exp. Date: __ __ / __ __

CVV Code: __ __ __ __ (code on the back of credit card)

Credit Card Holders Name: __________________________________________________

Credit Card Holder's Billing 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: ____________________

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