$50.00 for 10 Sheets of Ice

$50.00 for 10 sheets of ice

GOALIES receive additional discount of 50%

Checks payable to: AIB General (non-refundable)

In order for registration to be complete you must have:

2016 Summer Ice Registration Form

Payment in Full

**USA Hockey Registration Form (see requirements below for non-AIB members)

**Players notregistered with Alaska Icebreakers for the 2015-16season must provide proof of USA Hockey registration with this registration form. Anyone not registered with USA Hockey for the 2014-15 season must complete registration with USA Hockey online for USAH insurance at www.usahockey.com, print confirmation page and attach it to this registration.

Print legibly and provide all information requested.

Player's Name ______First MI Last Date of Birth

Mailing Address ______Zip Code ______

Parent/Guardian's Names ______

Contact Phone Numbers ______

Family Email Address ______Goalie? (circle one) Yes / No

Parent / Guardian Medical Consent / Release

I hereby give my consent, in the event of injury or illness, for emergency medical treatment, hospitalization, or other medical treatment as may be necessary for the welfare of the above named youth, by a physician, qualified nurse, and/or hospital during all periods of time in which the youth is away from his/her legal residence as a member of Alaska Icebreakers (AIB) and its affiliate. Further, I waive, on behalf of myself and the above named youth, any liability of the Alaska Icebreakers (AIB) and its affiliate, its agents, or Board Members, arising out of such medical treatment. I / We understand ice hockey is a contact sport and could result in serious injuries, and that protective equipment does not prevent all injuries to players. I / We, the parents or guardians of the above named player, hereby give my / our approval for him / her to participation any and all Alaska Icebreakers (AIB) and its affiliate’s activities. I / We assume all risks and hazards incidental to such participation including transportation to and from the activities; and I / We do hereby waive, release, absolve, indemnify and agree to hold harmless Alaska Icebreakers (AIB) and its affiliate, the organizers, sponsors, supervisors, participants, and persons transporting my / our children to or from activities, for any claim arising out of any injury to my / our child, whether the result of negligence or from any other cause.

Signature of Parent / Guardian: ______ Date: ______

Rev. 12/12/2018