Please Complete all Information. Please Print.
 Student's Name:___________________________________________
 City/State:____________________ Zip:___________
 Home Phone:________________ Parent’s Work Phone:________
 Ht.:__________ Wt.:___________ Birth Date:________________

 Email address:______________________________________________          

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:_________________________________

2019 Winter Clinic Locations, Tuition and Dates
                                 Please Mark Your Choice(s)

      City/State Price Arena, Date
O     Rochester, NY $65.00 Lakeshore Hockey Arena, Dec. 26 - 27
O     Hershey, PA $80.00 Hersheypark Arena, Dec. 26 - 27
O     Reisterstown, MD $85.00 Reisterstown Sportsplex,  Dec. 27 - 28
O     Lockport, NY $85.00 Cornerstone Ice Arena, Dec. 28 - 29
O     Waldorf, MD $85.00 Capital Clubhouse Rec. Center, Dec. 28 - 29
O     Alexandria, VA $90.00 Mt. Vernon Rec. Center, Dec. 30 - 31
O     Buffalo, NY $70.00 Holiday Twin Rinks, Dec. 30 - 31
Clinic Tuition, Is Based On Ice Prices In Each Individual City!
     Available Discounts
(Please Mark Your Discount for Credit -
One Discount Max. Per Transaction)
O   5% Family Discount (2 or more family members)
O   5% Returning Student Discount

Please Register My Son/Daughter For The following Extras;

O   DVD Professional Skill Analysis ($18.00 additional cost - includes shipping & Handling)

Please Send Me Additional Information
O   Clinic Brochures For Friends #_____
     Please Indicate Your Method and Amount of
     Payment For Our 2019 Winter Clinic
O  Check/Money Order:    $____________________

O  Visa   O  Master Card   O  Discover:    $____________________

 Card # __ __ __ __ / __ __ __ __ / __ __ __ __ / __ __ __ __
 Exp. Date: __ __ / __ __  CVV Code (back of card) __ __ __
 Credit Card Holder's Name: _____________________________________

Credit Card Holder's Billing Address:____________________________________________
 Authorized Signature: _________________________________________

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.

Signature: __________________________________________________
Date: ____________________

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