Hockey Pre-Registration Form

Please complete all required fields below.  By submitting this form, your child will be added to the roster for the requested program, however participation cannot begin until full payment has been made.  Registrations with invalid contact information will be discarded.

*DO NOT SUBMIT ANY CREDIT CARD INFORMATION THROUGH THIS FORM*

If you are unsure of the days/times programs are offered, please refer to the flyer for that program, all of which can be found on our web site, prior to completing the form.

Program Name: *	Adult Hockey Clinic Future Rangers Power Skating Clinic Recreational In-House Hockey
Day of Class/Program:	Tuesday Power Skating Wednesday Future Rangers Thursday Power Skating Friday Future Rangers Saturday Future Rangers Sunday Future Rangers Not Sure House League
Level:	Mite Squirt Pee Wee Bantam Beginner Intermediate Advanced Not Sure
Participant's Name: *
Age: *
Birth Month	January February March April May June July August September October November December
Birth Date:	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Birth Year:	1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Parent/Guardian's Name: *
Primary Phone#: *
Secondary Phone#:
Email Address: *
Street Address: *
City/Town: *
State:	AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - Washington DC DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming Not USA
Zip Code:
Payment Method:	I will call in my credit card info I will mail a check I will pay in person
Additional Information:
	The above named shall hold the Brewster Ice Arena, Southeast Sports Complex, their officers, employees, and volunteers harmless from and against any and all liability, loss, expenses (including attorney fees) or claims for injury or damage arising from participation in any programs and/ or related activities. Under N.Y. State Law, a skater assumes the inherent risks of skating. N.Y.S. Law imposes a duty on you to understand these risks. If you are not willing to assume these risks then skating at the Brewster Ice Arena is PROHIBITED.
Security Code: *
	By clicking the 'Submit' button on this form, you acknowledge that you have read and agree to the terms and conditions stated above.