Player Name:
Birthdate:
Address:
City: State: —Please choose an option—PAMDDE Zip:
Phone:
School Districts:
2025 – 26 Grade: —Please choose an option—Pre-KK123456789101112

Position*: ForwardDefenseGoalie
2025 – 26 Playing Level: —Please choose an option—TravelHouseBeginner
Last Year’s Club:
No. Years Hockey: —Please choose an option—01234567891011More
Parent’s Name:
Parent’s Work Phone:
Parent’s e-mail:
Emergency Contact & Number:
Doctor’s Name & Number:
Medical History: (Please list any recent operations, current medication, Injuries within the past two years)

PLEASE READ THE FOLLOWING STATEMENT BEFORE SUBMITTING
I, the parent or guardian, understand the inherent risk of physical injury involved in ice hockey and do so at my own risk. Participants and parents assume responsibility for all injuries and damage and forever release, discharge and hold harmless the employees and agents of the Regency Ice Rink from any and all claims, demands, and rights of action, present and future resulting from participation in any program or use of the facilities.

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