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*:      
Returning Student*:
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
06.26.2017-06.30.2017Cincinnati / OHSports Plus Arena$350.00
Only goalie registrations accepted for Cincinnati
Full06.26.2017-06.30.2017Alexandria / VAMt. Vernon Rec. Center$500.00
06.26.2017-06.30.2017Rockville / MDRockville Ice Arena$520.00
Only goalie registrations accepted for Rockville
07.05.2017-07.08.2017Altoona / PAGalactic Ice$250.00
07.10.2017-07.14.2017Cicero / NYCicero Twin Rinks$325.00
Only player registrations accepted for Cicero
07.10.2017-07.14.2017Raleigh / NCRaleigh Iceplex$425.00
Only player registrations accepted for Raleigh
07.10.2017-07.14.2017Hershey / PAHersheypark Arena$360.00
Only goalie registrations accepted for Hershey
07.17.2017-07.21.2017Lockport / NYCornerstone Ice Arena$295.00
07.17.2017-07.21.2017Greensboro / NCIce House of Greensboro$400.00
07.17.2017-07.21.2017Fairport / NYThomas Creek Ice Arena$315.00
07.24.2017-07.28.2016Albany / NYAlbany County Hockey Facility$350.00
07.24.2017-07.28.2017Richmond / VARichmond Ice Zone$425.00
Only player registrations accepted for Richmond
07.24.2017-07.28.2017Rockville / MDRockville Ice Arena$520.00
07.31.2017-08.04.2017Buffalo / NYLeisure Rinks$290.00
Only goalie registrations accepted for Buffalo
07.31.2017-08.04.2017Reston / VASkateQuest of Reston$475.00
07.31.2017-08.04.2017Alexandria / VAMt. Vernon Rec. Center$500.00
08.07.2017-08.11.2017Randolph / NJAspen Ice Arena$525.00
08.07.2017-08.11.2017Reisterstown / MDReisterstown Sportsplex$425.00
Only player registrations accepted for Reisterstown
08.07.2017-08.11.2017Cicero / NYCicero Twin Rinks$325.00
08.14.2017-08.18.2017Ithaca / NY"The Rink" - Lansing$375.00
08.14.2017-08.18.2017Rockville / MDRockville Ice Arena$520.00
08.14.2017-08.18.2017Rochester / NYLakeshore Hockey Arena$285.00
08.21.2017-08.25.2017Cortland / NYJM McDonald Sports Complex$365.00
08.21.2017-08.25.2017Hooksett / NHTri-Town Ice Arena$400.00
08.21.2017-08.25.2017Buffalo / NYLeisure Rinks$290.00
08.28.2017-09.01.2017Niagara University / NYDwyer Arena$300.00

Available Discounts - maximum of 1 discount per registration
(your discount will be automatically calculated upon check out)
*10% for 2 or more different Registration dates
n/a
n/a
*
*
SUMMER CAMP CANCELLATION POLICY: In the event of a cancellation, your deposit would be credited towards the following summer. In extreme cases a refund may be issued, but a $100.00 administration fee would be implemented. Refunds will not be considered regarding any issues, within 2 weeks prior to your chosen week (Credit Only).

I would also like to purchase the:  Individual DVD (Personalized Skill Analysis of your son or daughter)
($15.00)
 Individual Flash Drive(Personalized Skill Analysis of your son or daughter)
($20.00)
 Group DVD (Game Tape Analysis of your son/daughter's SIHA group)
($15.00)
** NOTE: Be sure to choose either our Individual DVD or Flash Drive, if you would like a copy of your son/daughter's professional analysis.

Please register my son/daughter for the following Lunch Program:  "No Meals"
 "Youth Meal" Lunch Program
($37.00)
 Fairport/Niagara/Rochester/Rockville "Youth Meal" Lunch Program
($47.00)
 "Big Kid Meal" Lunch Program
($48.00)
 Fairport/Niagara/Rochester/Rockville "Big Kid Meal" Lunch Program
($58.00)

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. 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