Document 6495300

How To Do This 1) Download and print this packet of forms. You should have 5 pages in addition to these instructions: 1. Brattleboro Hockey Assoc (BHA) Registration form. 2. BHA Fees and Terms of Payment 3. USA Hockey Participant Code of Conduct 4. USA Hockey Consent to Treat/Medical History Form 5. BHA Parent Code of Conduct 2) Tell your kids you are working on their happy childhoods and to leave you alone for a few minutes. 3) Enter your skater’s information at the top of the BHA Registration form. Look at the USA Hockey Age Classification chart to the right to select the proper division for your child. Enter the division in the Level/Team space. A. If you are unsure of your skaters skill level and where they belong, contact one of the coaches or a BHA board member. You will find their contact info on our website. Complete the rest of the BHA Registration with your information 4) Locate your skater’s division on the Fees and Terms of Payment page and check that box. Select a payment plan, do the math, complete the bottom line, date and sign. Almost done. 5) Go over the Participant Code of Conduct with your skater and be sure they understand it. Please have them sign their names at the bottom. 6) Fill out the Consent to Treat/Medical History Form, date and sign. 7) Read the BHA Parent Code of Conduct. Fill in the names, date and sign. 8) One more thing, then you’re done. All skaters are required to register with USA Hockey, which is a separate process from the BHA as well as cheaper and easier. The fee is $40 and can be done entirely online at www.usahockeyregistration.com/register. There is also a link on the BHA’s on line registration page. Once you have completed the USA Hockey registration and printed your certificate of confirmation, place it with the BHA forms covered in the above steps and mail to: Debbie Taggard BHA Registrar 939 Meadowbrook Road Brattleboro, VT 05301 (You can also bring it to the equipment sale&swap at the rink on Sat Sept.8 from 10a-­‐1p) BHA
P.O. Box 1
Brattleboro VT 05302
www.brattleborohockey.org
Brattleboro Hockey Association (BHA)
Developing good sports since 1976
2012-2013 Registration
Skater’s name_____________________________
Date of birth______________________________
(USA Hockey requires BHA to retain a Birth Certificate copy)
Male ______ Female ______
USA Hockey Age Classifications
Novice
Mites
01/01/04 & after
Squirts
01/01/02 - 12/31/03
Pee Wees
01/01/00 - 12/31/01
Bantams
01/01/98 - 12/31/99
Midgets
01/01/94 - 12/31/97
U-14 Girls
01/01/98 & after
Learn-to-Skate
Level / Team: _____________________________
The BHA is a member of the Greater Springfield League (GSL) based in Springfield, MA. If not in the GSL league,
games are scheduled independently in VT and the region by the team.
Parent name:
Parent name:
* Please circle only one address/email
for billing
Address
Address
Town
State & Zip
Phone
Town
State & Zip
Phone
E-mail
E-mail
I recognize that playing ice hockey presents the possibility of injury. I give my permission for the abovenamed skater to participate in any and all of the activities of the hockey program. I assume all risks and
hazards incidental to these activities. I do hereby further release from liability, absolve, indemnify and
hold harmless the Brattleboro Hockey Association, its directors, officers, sponsors and coaches for any
injury sustained by the above-named skater while participating in a Brattleboro Hockey Association
related game or practice.
_________________________________________________________Date_________________
Parent(Guardian) Signature
Permission to Use Images
I, ___________________________, grant permission for images taken during the 2012-2013 season
of my daughter/son ,_________________________ to be used by the BHA for publicity and/or award
purposes.
__________________________________________________________Date________________
Parent (Guardian) Signature
BHA
P.O. Box 1
Brattleboro VT 05302
www.brattleborohockey.org
2012-2013 Fees and Terms of Payment
Team Fee (doesn’t include registration deposit; one third of remaining balance due on 10/15/12,
second due 11/15/12 and final balance due 12/15/12.) If final balance is not paid by 12/15/2012,
penalty will be at the discretion of the BHA Board of Directors and may include the player being
denied ice time until paid in full.
LEVEL
TOTAL
DUE
___ Learn to Skate
=
Registration
Deposit
+
Team
Fee
Free
for 1 season
___ Novice
Free
01/01/05 & after
___ Mites
590.00
400.00
190.00
64./ month x3
800.00
400.00
400.00
134./ month x3
920.00
400.00
520.00
174./ month x3
1025.00
400.00
625.00
207./ month x3
575.00
400.00
175.00
59./ month x3
01/01/04 & after
___ Squirts
01/01/02 - 12/31/03
___ Pee Wees
01/01/00 - 12/31/01
___ Bantams
01/01/98 - 12/31/99
___ U-14 Girls
01/01/98 & after
Please check those that apply:
___ Pay in full
** PAYPAL OPTION AVAILABLE - SEE WEBSITE FOR DETAILS
___ Installment payments: 10/15/12, 11/15/12 and 12/15/12
___Additional Skater Discount, @ $50. after 1st skater. Will be deducted from ‘12-‘13 season final payment
to those qualifying families who are paid in full by 12/15/12
___Scholarship application available on website, must be submitted with registration,
st
st
as funds are 1 come, 1 served. Mail to BHA, P.O. Box 1, Brattleboro, VT 05302, attn: Scholarship Committee
___Goalie Discount / (1/2 of registration deposit and team fee) Applies to Squirt level through Bantam
and only those players dedicated to playing goalie and supplying all their own gear.
___$ 15.00 non-Brattleboro Resident Fee, (due at registration; payable to BHA)
Total due at Registration $ _______ Check#_______ Amount Pd.$________ Date______
Along with the full BHA registration, available from www.brattleborohockey.org , a 2012-2013 season
USA Hockey registration must be completed for each skater. Go to www.usahockey.com. Once
registered and having paid the ‘12-‘13 USA Hockey Individual Membership Registration (IMR) fee, and
a State fee, the USA Hockey confirmation receipt and BHA registration forms must be submitted to the
BHA c/o Debra Taggard, Debbie Taggard [email protected] 939 Meadowbrook Road
Brattleboro, VT 05301802-257-7802 before any skater is allowed to skate.
I agree to pay the above fees according to stated terms of payment, final balance due December 15,
2012 (No refunds after November 15, 2012). I also agree to participate in fundraising activities for the
organization which helps to keep the registration fees from being higher.
Parent (Guardian) Signature
_________________________________________________Date________
Thank you for registering with the BHA
USA HOCKEY
PARTICIPANT
CODE OF CONDUCT
NAME:___________________________________________________
P.A.L. Hockey
To be read and signed by you as a member of Team: ____________________
2011 - 2012 season.
Participating in USA Hockey for the ____________
1.
No swearing or abusive language on the bench, in the rink, or at any team
function.
2.
No lashing out at any official no matter what the call is. The coaching staff
will handle all matters pertaining to officiating.
3.
Anyone who receives a penalty will skate directly to the penalty box.
4.
Fighting will not be tolerated. Fighting will result in an appearance before a
Discipline Committee.
5.
There will be no drinking, smoking, chewing of tobacco or use of illegal
substance at any team function.
6.
I will conduct myself in a befitting manner at all facilities (ice rink, hotel,
restaurant, etc) during all team functions.
7.
Any player or team official who cannot abide by these rules or violates
them will be subject to further disciplinary action.
Signed: _______________________________ Date:___________________
Form 1-P Rev 02/09
DocQ. Securely Send, Sign, Store and Edit Your Documents with DocQ.com
BRATTLEBORO HOCKEY ASSOCIATION
PARENT CODE OF CONDUCT
As the parent or guardian of a hockey player, I pledge to:
1. Help make hockey fun and safe for everyone involved;
2. Be a good sport myself and encourage fair play and teamwork in others;
3. Cheer good play on both sides. Avoid negative comments toward any
player, including my child, both on and off the ice;
4. Refrain from any negative comment and/or action toward referees,
coaches, players and/or spectators;
5. Leave all coaching to the coaches;
6. Show respect and appreciation for the volunteers who give their time for
my child;
7. Bring concerns directly to the coach or Board of Directors, should I have
any.
I have read and understand this Parent Code of Conduct. I understand that if I
violate this Parent Code of Conduct, my family may forfeit membership in the
Brattleboro Hockey Association at the sole discretion of the Board of Directors.
Name of player(s):
Printed name of parent(s) or guardian(s):
Signature of parent(s) or guardian(s):
Date:
USA Hockey
Consent To Treat/Medical History Form
This is to certify that on this date, I __________________________________________, as parent or
guardian of __________________________________________, (athlete participant), or for myself as an
adult participant, give my consent to USA Hockey and its medical representative to obtain medical
care from any licensed physician, hospital, or clinic for the above mentioned participant, for any injury
that could arise from participation in USA Hockey sanctioned events.
If said participant is covered by any insurance company, please complete the following:
Insurance Company: ___________________________________________________________
Policy Number: _______________________________________________________________
Parent/Guardian/Adult Participant Signature: _____________________________
Date: __________
Excess accident insurance up to $25,000, subject to deductibles, exclusions and certain limitations,
is provided to all USA Hockey registered team participants. For further details visit usahockey.com or
contact USA Hockey at (719) 576-USAH.
EMERGENCY CONTACT
Name: ___________________________________________________
Phone: _____________________
Address: _________________________________________________________________________________
Physician’s Name: ________________________________________
Phone: _____________________
Hospital of Choice: ________________________________________________________________________
COMPLETION OF MEDICAL HISTORY INFORMATION BELOW IS OPTIONAL
MEDICAL HISTORY
If the answer to any of the following questions is yes, please describe the problem and its implications
for proper first aid treatment on the back of this form.
❑
Head Injury
(concussion, skull fracture)
❑
❑
❑
Fainting spells
Convulsions/epilepsy
Neck or back injury
❑
❑
❑
❑
❑
Asthma
High blood pressure
Kidney problems
Hernia
Heart murmur
❑
❑
❑
Allergies _________________
Diabetes
Other ____________________
_________________________
_________________________
Have you had (or do you currently have) any of the following?
Have you had a recent tetanus booster?
❑ Yes ❑ No If yes, when? _________________________
Are you currently taking any medications? ❑ Yes ❑ No If yes, please list all medications on back.
Has a doctor placed any restrictions on your activity? ❑ Yes ❑ No If yes, please explain on back.
3C Rev 2/09