Corning Youth Hockey Registration

2005/2006 

PLAYER NAME___________________________________

DATE OF BIRTH___/___/___PRESENT AGE________________________

ADDRESS__________________________CITY, STATE, ZIP____________________

HOME PHONE_______________________CELL PHONE_________________

LIST ANY MEDICAL CONDITIONS (Asthma, allergies, injuries, etc.):

• PAYMENT IS REQUIRED TO REGISTRATION FOR TOTS, SHARKS & RANGERS.
• DO NOT SEND PAYMENT FOR GIRLS, SQUIRT, PEEWEE OR JV DIVISIONS.  YOU WILL RECEIVE MORE  PAPERWORK AND PAYMENT INSTRUCTIONS IN THE MAIL!!! 
• RETURN REGISTRATION FORM TO

CORNING PARKS AND REC, 1 CIVIC CENTER PLAZA, CORNING, NY 14830

YOUR SON/DAUGHTER WOULD LIKE TO PLAY  IN (Check one): 

____________     TOT HOCKEY I: AGES 4 & 5, $75 

____________     TOT HOCKEY II: AGES 5 & 6, $75 

____________     SHARKS: AGES 6 - 7, $100 

____________     RANGERS: AGES 7 - 9, $125 

____________     USA SQUIRT HOCKEY: AGES 9 – 10,$225 

____________     USA PEEWEE HOCKEY: AGES 11 - 12, $300

____________     JV (USA BANTAM HOCKEY): AGES 13 – 14, $300

____________     USA GIRLS HOCKEY 12U: AGES 16 & UNDER, $250

I hereby give permission for my son/daughter to play in the City of Corning Youth Hockey Program.  I understand that hockey is a dangerous sport and can result in serious injury and even death.  I am legally responsible for this child and I hereby assume all risks for my minor child incidental to the game of hockey, including but not limited to, the danger of being injured by pucks, hockey sticks, skates, collisions with the boards, ice, goals or other players and staff and volunteers.  I agree to provide medical insurance for my child and I agree to pay all medical expenses above and beyond the amount covered by my insurance.  I agree to allow staff members to render first aid and call an ambulance in my absence. 

PARENT/LEGAL GUARDIAN ________________________________  DATE______