Player InformationPlayer's Name*Parent/Guardian's NameAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Position* Goalie Foward DefensemanShooting Hand* Right Hand Left HandHockey ExperiencePlease give us a brief description of your player's hockey experience.Program SelectionLevel Selection*Session Selection2006 AYHL AAA Bantam Minor - $1252005 AYHL AAA Bantam Major - $1252004 and 2003 AYHL AAA Midget 15U/16U - $1252002 and 2001 AYHL AAA Midget 18U - $125Elite Girls 14U - $125Elite Girls 16U - $125Elite Girls 19U - $125Session Date: April 10, 11 & 12, 2019 Time: 6:00 p.m.-7:15 p.m. on Rink 3Session Date: April 10, 11 & 12, 2019 Time: 6:00 p.m.-7:15 p.m. on Rink 3Session Date: April 10, 11 & 12, 2019 Time: 7:30 p.m.-9:30 p.m. on Rink 3Session Date: April 10, 11 & 12, 2019 Time: 7:30 p.m.-9:30 p.m. on Rink 3Session Date: April 10, 11 & 12, 2019 Time: 6:30 p.m.-7:45 p.m. on Rink 4Session Date: April 10, 11 & 12, 2019 Time: 8:00 p.m.-9:15 p.m. on Rink 4Total $0.00 Payment InformationCardholder Name*Card Type*Select Card TypeVisaMastercardDiscoverAmerican ExpressCard Number*CCIDExpiration Month*Select MonthJanFebMarAprMayJunJulAugSepOctNovDecExpiration Year*Select Year201820192020202120222023202420252026202720282029Medical Emergency Statements* Yes, I agree with the following Medical Emergency StatementsHold Harmless Agreement The above applicant agrees to follow the rules and regulations of IceWorks and releases an holds harmless Iceworks, from any and all injury and all liability, loss or damage. Assumption of Risk Agreement and Release Upon entering events sponsored by IceWorks and/or its Agents or Affiliates, I/We abide by the rules of IceWorks as currently published. I/We understand and appreciate that participation or observation of sports constitutes a risk to me/us of serious injury, including permanent paralysis or death. I/We voluntarily knowingly recognize, accept, and assume this risk and release IceWorks, it affiliates, their sponsors, events organizers and officials from any liability thereof. Medical Release The above applicant does hereby authorize IceWorks and its employees and agents to make any and all decisions in my absence regarding medical emergency treatment of the above applicant and to sign the necessary hospital release forms in order to obtain medical attention. In case of emergency I can be reached at the number provided in the above form. Please check the box provided to indicate your agreement with regard to the above Medical Emergency and Assumption of Risk statements. Upon submission of this form, user/applicant agrees that he/she is over 18 years of age or is the legal guardian of the person indicated in the "Player's Name" field of this form. This iframe contains the logic required to handle Ajax powered Gravity Forms.