Junior IceHogs Skill Development Program

register
Four convenient ways to register
ONLINE • rockfordparkdistrict.org » Click MyRPD
MAIL-IN
Rockford Park District Customer Service
401 S. Main St. STE 109 – Rockford, IL 61101-1321
coaches
Top Level Coaching
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Head Coach Rockford Icemen (16-time combined state champs)
2 004 Head Coach Rockford IceHogs (USA Hockey Master Level 5)
AHIA 2015 Hall of Fame Inductee
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Played eight years professional hockey
Coached three years professional hockey
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Payment options
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Automated payment plans are available
for Rockford Park District programs. This option requires the
head of household to register in person at either Customer
Service office and sign agreements for the District to withdraw
regular payments from their bank account and/or credit card.
Contact Customer Service for more information on this
payment option.
D
on Walker
U SA Hockey Master Level 5 Coach
Played one year professional hockey
30 years coaching experience
Customer Service Satellite Office, Carlson Ice Arena
4150 N. Perryville Rd. – Loves Park, IL
Mon–Fri, 8:00 am–8:00 pm • Sat, 8:00 am–12:00 pm
Payment is required at the time of registration. We accept
cash, personal checks, credit cards (American Express, Visa,
MasterCard, and Discover Card only) and debit cards on which
the VISA or MasterCard logo appears. Please make checks
payable to ROCKFORD PARK DISTRICT.
S
cott Burfoot
2003 Head Coach Rockford IceHogs (USA Hockey Master Level 5)
FAX (credit card payments only) • 815-987-8877
IN PERSON
RPD Customer Service, Webbs Norman Center
401 S. Main St. – Rockford, IL
Mon–Fri, 8:30 am–5:00 pm
T
im Mattila
F
rank Casalena
USA Hockey Level 5 Coach
Coached the Rockford Hockey Club’s Bantam AA for 12 years
Coached 8 years for the Kenosha Komets youth hockey club
E
ric Brown
USA Hockey Certified Coach
Played Madison Capitols AAA Team (2002-2008)
Played at Illinois State University (2008-2013)
Illinois State All-Time Leading Scorer
RHC Assistant Coach (2015-2016)
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J on Larson
USA Hockey Level 4 Coach
Played for Chicago Mission AAA (MWEHL) 2003-2007
Played for Kenai River Brown Bears (NAHL) 2007-2008
Jr. IceHogs instructor since 2005
RHC Assistant Coach 2011-2012
Rockford Icemen Varsity/CSDHL Assistant Coach 2012-2013
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• Just 75 minutes from
Chicago’s O’Hare Airport,
Milwaukee, and Madison
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BOARD OF COMMISSIONERS Jack L. Armstrong • Douglas J. Brooks • Julie Elliott
Ian K. Linnabary • Tyler Smith EXECUTIVE DIRECTOR Tim Dimke
We welcome the opportunity to assist guests with disabilities to enjoy
ALL our facilities, programs, and services. For assistance and information
on accessibility, contact Customer Service at 815-987-8800
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JUNIOR ICEHOGS
TRAINING FACILITY
312 N. Madison St.
Rockford, IL
57
• 2 .5 hours from
Bloomington
[email protected]
rockfordparkdistrict.org • 815-962-2412
SKILL
Development
Program 2016
junior icehogs
Skill Development Program
1. PARTICIPANT REGISTRATION INFORMATION
The Junior IceHogs Skill Development
Program in Rockford, IL is offering top
level coaching and competition.
HH ID#_______________
registration
Last name
First
Middle
Address
CityState
ZIP
Home phone
Birth date
Parent/Guardian Name
Work Phone
/
/
Age
Male
E-mail address (optional)
• O
ff-ice training, including unlimited use of
RapidShot, hockey’s answer to a batting cage
Is it okay for us to contact you by e-mail about the programs you have registered for?
Yes
No
Are you interested in receiving information via e-mail with special Rockford Park District promotions,
upcoming events, registration, and announcements?
Yes
No
Does participant have allergies that may require medication (i.e., EpiPen, Benadryl, etc.)? Yes
•
Unlimited use of the training facility for the season
Will participant need to take medication during program hours?
• 5
0% registration discount for the Spring Junior
IceHogs League
Does participant have a disability or medical condition that may require assistance or accommodation?
(i.e., diabetes, seizures, mental illness, conduct/behavior disorder, physical disability, developmental delay)
Our high-level competitive environment will include:
BEST VALUE FOR THE PRICE ANYWHERE!
JUST $495 ($550/non-residents)
SPRING SEASON
APRIL 5–JUNE 9, 2016
All players should be USA Hockey registered.
Additional tournament fees may apply.
TEAM TRYOUTS
$35/resident • $40/non-resident
March 28–31, 2016
(SEE TIMES BELOW)
MITES SQUIRTS PEEWEES
BANTAMS
MIDGETS
Birth year 2008-09. . . . . . . . . .
Birth year 2006-07. . . . . . . . . .
Birth year 2004-05. . . . . . . . . .
Birth year 2002-03. . . . . . . . . .
Birth year 1999-2001. . . . . . . .
ID# 150502-01
ID# 150502-02
ID# 150502-03
ID# 150502-04
ID# 150502-05
TRYOUT TIMES (AT RIVERVIEW ICE HOUSE)
3/28 – Mites 6:30 pm; Midgets 7:30 pm
3/29 – Squirts 6 pm; PeeWee 7 pm;
Bantam 8 pm
3/30 – Mites 6 pm; Squirts 7 pm
3/31 – PeeWee 6 pm; Bantam 7 pm;
Midgets 8:30 pm (at Carlson Ice Arena)
Female
Yes
No
No
If answering yes to either medication
question, please request the Permission
to Administer Medication Form from
Customer Service
Yes
No
2. EMERGENCY INFORMATION Please list any adult (age 18+) whom we should contact in case the parent/guardian cannot be reached
in the event of any emergency.
Contact Name
Phone #1
Phone #2
Relationship
3. PAYMENT INFORMATION W
ould you like to make a donation to the Rockford Park District Fee Assistance program to aid kids who need
financial help to participate in RPD programs?
Yes $ __________________
No thank you
Credit card #
Exp date
Total of all fees $
Signature (Authorization for credit card use)
IMPORTANT INFORMATION
The Rockford Park District is committed to conducting its
recreation programs and activities in a safe manner and
holds the safety of participants in high regard. The District
continually strives to reduce such risks and insists that
all participants follow safety rules and instructions that
are designed to protect the participants’ safety. However,
participants and parents/guardians of minors registering
for this program/activity must recognize that there is an
inherent risk of injury when choosing to participate in
recreational activities/programs. You are solely responsible
for determining if you or your minor child/ward are
physically fit and/or adequately skilled for the activities
contemplated by this agreement. It is always advisable,
especially if the participant is pregnant, disabled in any way
or has recently suffered an illness, injury or impairment, to
consult a physician before undertaking any physical activity.
WARNING OF RISK
Hockey is a sport intended to challenge and engage
the physical, mental and emotional resources of each
participant. Despite careful and proper preparation,
instruction, medical advice, conditioning and equipment,
there is still a risk of serious injury, including but not
limited to head/brain injury, cervical spine injury (including
paralysis) and death. All hazards and dangers cannot be
foreseen. The very nature of the game of hockey is hazardous
and risky, including but not limited to being tripped, bodychecked, cross-checked with the stick, hit with a slash, a
high stick, or a thrown stick, going head first into the boards,
getting pushed or checked from behind, being cut by a skate
blade, colliding with goal posts, being hit by a stick, puck,
or other player’s protective equipment, elbowed in the head
or face, collisions with other players and stationary objects,
poor officiating, injuries caused by failure to wear adequate
protective equipment, inadequate playing conditions,
defective equipment, imperfections in the ice, failure in
supervision or instruction, unsportsmanlike conduct, and
all other circumstances inherent to the sport of hockey. In
this regard, it is impossible for the Rockford Park District to
guarantee absolute safety.
WAIVER AND RELEASE OF ALL CLAIMS
AND ASSUMPTION OF RISK
Please read this form carefully and be aware that in
signing up and participating in this program/activity, you
will be expressly assuming the risk and legal liability and
waiving and releasing all claims for injuries, damages or
loss which you or your minor child/ward might sustain as
a result of participating in any and all activities connected
with and associated with this program/activity (including
transportation services/vehicle operation, when provided).
I recognize and acknowledge that there are certain risks
of physical injury to participants in this program/activity,
and I voluntarily agree to assume the full risk of any and
all injuries, damages or loss, regardless of severity, that
my minor child/ward or I may sustain as a result of said
participation. I further agree to waive and relinquish all
claims I or my minor child/ward may have (or accrue to me or
my child/ward) as a result of participating in this program/
activity against the Rockford Park District, including its
officials, agents, volunteers and employees (hereinafter
collectively referred to as “District”). I do hereby fully release
and forever discharge the District from any and all claims for
injuries, damages, or loss that my minor child/ward or I may
have or which may accrue to me or my minor child/ward and
arising out of, connected with, or in any way associated with
this program/activity. I have read and fully understand the
above important information, warning of risk, assumption of
risk and waiver and release of all claims. If registering online
or via fax, my online facsimile signature shall substitute for
and have the same legal effect as an original form signature.
waiver
4. PARTICIPATION WILL BE DENIED if the signature of adult participant or parent/guardian and date are not on this waiver.
Participant’s name (PLEASE PRINT) __________________________________________________________________________
Parent/guardian or adult participant signature___________________________________________________Date______________