______________________ Roller Hockey Team 2004\2005 Season

Registration Information

Date:

/ /

Tryout #

Player Last Name:

Player First Name:

Date of Birth:

/ /

Grade:

Current Accum. GPA:

Guardian Name(s):

Street:

Apt.

City:

State:

Zip:

Player Phone Numbers

Guardian Phone Numbers

Home Phone:

( ) -

Home Phone: ( ) -

Home Phone (Alt): ( ) -

Cell Phone:

( ) -

Work Phone: ( ) -

Work Phone (Alt): ( ) -

Cell Phone:

Cell Phone

Email Player:

Email Parent:

Emergency contact:

Name:

Phone: ( ) -

Insurance Information:

Insurance Co

Policy Number:

Preferred Positions (pick 1st and 2nd):

Defense (Left)

Forward (Left)

Goalie

Defense (Right)

Forward (Right)

Practice Time Availability: (Specific Hours, please)

Notes:

Sunday

morning:

afternoon:

evening:

Monday

morning:

afternoon:

evening:

Tuesday

morning:

afternoon:

evening:

Wednesday

morning:

afternoon:

evening:

Thursday

morning:

afternoon:

evening:

Friday

morning:

afternoon:

evening:

Saturday

morning:

afternoon:

evening:

The _________ High School Roller Hockey team is not affiliated directly with ______ High School. It is an extracurricular activity in association with the __________ Roller Hockey League. The league is sanctioned by USA Hockey Inline and membership in USA Hockey Inline is a requirement for all players. Supplemental Insurance is provided by membership in USA Hockey Inline as defined in the USA Hockey Inline Insurance brochure provided to each player. Each participating member of the ______ Roller Hockey Team must carry personal medical insurance to cover any possible injuries that occur through practices, scrimmages or games.
Parents are responsible for ensuring that players have safe and reliable transportation to and from practice and game locations as scheduled throughout the season.

League Use Only
Received by:

Signature of Legal Guardian:

Date:

/ /

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