Mt Prospect Park District

2018

Spring Youth Ice Hockey LeagueRegistration Form

Player’s Name:Date of Birth ___/___/___ ⃝ Male ⃝ Female

Address: City:St: Zip:

Father’s Name: Phone #: ______Email:

Mother’s Name: Phone #: Email:

Emergency #:Emergency Contact:

Team Played for previous Hockey Season:

Players MUST register annually with AAU (Mite maj.) or USA Hockey (Squirt - Peewee) to be eligible to play. Visit aauhockey.org or usahockey.com to register your player and receive your AAU/USAH member number. Once registered, you must provide your AAU/USA Hockey number. Registration WILL NOT BE ACCEPTED unless the 2016/17 AAU/USA Hockey membership information is attached.

AAU/USA Hockey # (REQUIRED): ______

2018House League Registration Fees

Players (All Levels) - $500 Full Time Goalies (All Levels) - $325

Player - Mites(10/11/12) ⃝33010Full Time Goalie– Mites⃝33012

Player - Squirt (08/09) ⃝33009Full Time Goalie-Squirt⃝ 33012

Player - Peewee (06/07) ⃝33008Full Time Goalie - Peewee⃝ 33012

Player - Bantam (04/05) ⃝33011Full Time Goalie-Bantam⃝ 33012

Payment Options for 2018 Season (check one)

Choose One:⃝ Pay in Full

⃝ Payment Plan-$250 (per player) due at registration, (1)-$250 payment (4/18/2018)

⃝I agree to have my credit card automatically charged on the installment dates.

Payment Method:⃝ CashAmount $⃝ Check#Amount $

⃝ Credit Card Visa MC Disc Card #

Amount $ Exp. Date

Name on Card:

Cardholder Signature: ______

Make Checks Payable to: Mt Prospect Park District

For MPPD Office Only: Date Received: ______By: ______

For more information contact Jason Hickman or phone at 847-640-1000 x211.

Registration can be done online at or completed at any park district facility. The registration form must turned in to complete the registration process. All forms should be sent to Jason Hickman at RecPlex,420 W. Dempster St., Mt. Prospect 60056PLEASE SIGN WAIVER ON BACK

Mt. Prospect Park District Waiver & Release

I hereby agree to abide by all Mt. Prospect Park District rules and regulations as they pertain to the Park District facilities or services, and any resulting consequences for failing to abide by them. By their very nature, many Park District programs involve body contact, substantial physical exertion, emotional stress and/or use of equipment, which represents a certain risk of users. It is recommended that you check with your physician prior to participating in these activities. The Park District does not provide insurance protection for participants in Park District activities. Registration in any Park District program or purchase of any Park District facility use pass or admission assumes full responsibility on the part of the registrant for any risk, implicit or direct, by participation in said activity or facility. Further, the registrant agrees to the following:

  1. I fully recognizethe risks of injury or illness inherent in this program and represent to the Park District that I offer my authority for me or for my child to participate.
  2. I hereby release and discharge the Mt. Prospect Park District and its officers, directors, employees and volunteers from any and all claims, actions or causes of judgements whatsoever including attorney’s fees and costs, which might arise from said participation.
  3. I hereby execute this release and acknowledge that such participation is at my own risk.
  4. I hereby grant emergency treatment for myself or child if I cannot be reached.

Participant’s Name (please print)

______

Participant’s Signature/Legal Guardian Signature(If participant under 18 yrs.)

______Date: ______