SECKMAN ICE HOCKEY CLUB
2013/2014 Ice Hockey Fall League Registration______
Player's Name ______Birthdate ______
Address ______City/Zip ______
School District______
Email Address ______
Home Phone ______Players Cell Phone______
Fall 2013 School & Grade ______Position:______
Hockey History (i.e. Teams/Yrs): ______
______
Mother’s Name ______
Address ______City/Zip ______
Work Phone ______Cell Phone ______
Home Phone ______Email ______
Father’s Name ______
Address ______City/Zip ______
Work Phone ______Cell Phone ______
Home Phone ______Email ______
Emergency Contact Name ______
Relationship to player ______
Work Phone ______Cell Phone ______
Home Phone ______Email ______
Forms that will be needed prior to tryouts and to complete registration:
______COPY OF YEAR REPORT CARD-SPRING SEMESTER 2013
______MID-STATES REGISTRATION AND CONSENT FORM
(Done thru Midstates hockey website you will get a code from the club registrar
to be able to do this form)
______IMR (INDIVIDUAL MEMBERSHIP REGISTRATION) PAID RECEIPT
______USA HOCKEY CONSENT & MEDICAL HISTORY FORM
I, the undersigned parent or legal guardian of the above named minor, do voluntarily
desire to enroll said minor in the Seckman Ice Hockey Club and thereby agree to be
bound by the Bylaws and Rules and Regulations thereof. I certify that I am cognizant
of all the inherent dangers, risks and hazards associated with ice hockey.
In consideration of being permitted to enroll, I hereby voluntarily assume all risks of
accident or injury to the above named minor, to my person or property, whether
foreseen or unforeseen. Thereby release Seckman Ice Hockey Club, its employees,
agents, representatives, contractors, or affiliate associations, for any claim, liability,
demand or suit of any kind sustained, whether or not caused by negligence of
Seckman Ice Hockey Club, its employees, agents, representatives, contractors, or
affiliate associations. I further agree to hold Seckman Ice Hockey Club harmless from
any claim, liability demand or suit arising out of an alleged malfeasance, misfeasance
or nonfeasance arising in connection with the Seckman Ice Hockey Club.
This release shall be binding upon my heirs, administrators, executors and assigns.
I represent that I am of lawful age and legally competent to sign this release, that I
understand that the terms herein are contractual and that I have signed this document
as my own free act.
By signing this release, I certify that I have read and fully understand the conditions
herein provided. This release shall remain in full force and effect until such time as
I notify the Seckman Ice Hockey Club, in writing, of the cancellation of this release.
Player Signature ______Date ______
Parent/Guardian Signature ______Date ______
Parent/Guardian Signature ______Date ______
$300 deposit due at time of registration. (Refundable only prior to first day of tryouts)
Submit this form and check to address below. Checks payable to : Seckman Ice Hockey Club
c/o Dean Schwartz, PO Box 375, Imperial, MO 63052. Phone: 314-223-5312
(For Board User only):
Season: ______Check #/Amt: ______Date Rec'd: ______Rec'd By: ______
Seckman Ice Hockey Club seckmanhockey.com
P.O. Box 375 11/29/2011
Imperial, MO63052 Rev. 7