Mt Prospect Park District
2017 Spring
Youth Ice Hockey League Registration Form
Player’s Name:
Date of Birth ___/___/___ ⃝ Male ⃝ Female
Address:
City:
St:
Father’s Name:
Phone #: _________________Email:
Mother’s Name:
Phone #:
Emergency #:
Zip:
Email:
Emergency Contact:
Team Played for previous Hockey Season:
Players MUST register annually with AAU (Mite maj.) or USA Hockey (Squirt - Peewee) to be eligible to play.
Visit aauhockey.org or usahockey.com to register your player and receive your AAU/USAH member number.
Once registered, you must provide your AAU/USA Hockey number. Registration WILL NOT BE ACCEPTED
unless the 2016/17 AAU/USA Hockey membership information is attached.
AAU/USA Hockey # (REQUIRED): ________________________________
2017 Spring House League Registration Fees
Please check the age division in which you are registering. Players must attend evaluation sessions.
Dates and times for player evaluations are located at: www.teamsideline.com/mppd
Players (All Levels) - $400
Player - Mite Maj. (08/09)
Player - Squirt (07/06)
Player - Peewee (05/04)
Player - Bantam (02/03)
Full Time Goalies (All Levels) - $260
⃝ 30440
⃝ 30439
⃝ 30438
⃝ 30441
Full Time Goalie - Mite Maj.
Full Time Goalie - Squirt
Full Time Goalie - Peewee
Full Time Goalie - Bantam
⃝ 30572
⃝ 30573
⃝ 30574
⃝ 30575
Payment Options for 2017 Spring Season (check one)
All Spring League registrations must be paid in full at the time of registration
Payment Method: ⃝ Cash Amount $
⃝ Credit Card
Amount $
⃝ Check #
Visa
MC
Amount $
Disc Card #
Exp. Date
CRV #
Name on Card:
Cardholder Signature: ________________________________________________
Make Checks Payable to: Mt Prospect Park District
For MPPD Office Only: Date Received: __________ By: __________________________________________
For more information contact Jacob Kaplan at [email protected] or by phone at 847-640-1000 x217.
Registration can be done online by visiting www.mppd.org or can be done at any park district facility. The
registration form must be completed and turned in to complete the registration process. All forms should be sent
to Jake Kaplan at RecPlex, 420 W. Dempster St., Mt. Prospect 60056 PLEASE SIGN WAIVER ON BACK
Mt. Prospect Park District Waiver & Release
I hereby agree to abide by all Mt. Prospect Park District rules and regulations as they pertain to the Park
District facilities or services, and any resulting consequences for failing to abide by them. By their very
nature, many Park District programs involve body contact, substantial physical exertion, emotional stress and/or
use of equipment, which represents a certain risk of users. It is recommended that you check with your
physician prior to participating in these activities. The Park District does not provide insurance protection for
participants in Park District activities. Registration in any Park District program or purchase of any Park District
facility use pass or admission assumes full responsibility on the part of the registrant for any risk, implicit or
direct, by participation in said activity or facility. Further, the registrant agrees to the following:
1. I fully recognize the risks of injury or illness inherent in this program and represent to the Park District
that I offer my authority for me or for my child to participate.
2. I hereby release and discharge the Mt. Prospect Park District and its officers, directors, employees and
volunteers from any and all claims, actions or causes of judgements whatsoever including attorney’s
fees and costs, which might arise from said participation.
3. I hereby execute this release and acknowledge that such participation is at my own risk.
4. I hereby grant emergency treatment for myself or child if I cannot be reached.
Participant’s Name (please print)
_____________________________________________________
Participant’s Signature/Legal Guardian Signature (If participant under 18 yrs.)
_____________________________________________________
Date: _______________________