Detroit Hockey Academy
50950 Century Court
Wixom, MI 48393
(248) 926-5656
DetroitHockeyAcademy.com
The Detroit Hockey Academy
Registration Package
Congratulations and welcome to the Detroit Hockey Academy Family. Your participation as a parent and/or
guardian is critical to your child’s success as well as making our organization the best it can be.
Please feel free to contact us to meet the staff, visit the facility, and ask any questions you may have about our
organization, our program or how you can easily enroll your student for the upcoming school year. The Detroit
Hockey Academy is excited to play an active role in the academic and athletic development of our young players.
We look forward to meeting your family, and are eager to share our talents, experience and ambition as your
young player develops into the student and athlete they aspire to be.
Michigan’s premier athletic progressive training program will be led by former Red Wing, 11 year NHL pro and
current NHL coach, Manny Legace. Joining Manny will be his highly qualified staff with over 45 years of combined
coaching experience including former NHL forward Damian Surma.
Our academic leadership team is comprised of Gigi Legace ( [email protected] ) and Dale George
( [email protected] ).
Completing the information within this document accurately and completely is extremely important and will
ensure that your player is prepared and ready for a wonderful experience from the very first day of school.
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Detroit Hockey Academy
50950 Century Court
Wixom, MI 48393
(248) 926-5656
DetroitHockeyAcademy.com
Student Information
Full Name:
Birth Date:
Grade Entering:
Jacket Size:
Pant Size:
Team:
Position:
Phone Number:
Email:
Address:
Parent Information
Father:
Phone Number:
Email:
Address (if different):
Mother:
Phone Number:
Email:
Address (if different):
Billet / Guardian Information (if applicable)
Guardian Name(s):
Phone Number(s):
Relationship:
Email:
Address:
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Detroit Hockey Academy
50950 Century Court
Wixom, MI 48393
(248) 926-5656
DetroitHockeyAcademy.com
Emergency Contact Information
Emergency Contact:
 Father ( see previous page )
 Mother ( see previous page)
 Guardian ( see previous page )
 Other (enter information below)
Emergency Contact (Other):
Phone Number:
Relationship:
Email:
Address:
Medical Information
Health Insurance Provider:
Group Number:
Policy Number:
Preferred Hospital:
Family Doctor:
Allergies:
Medications:
Known Restrictions:
Known Medical Conditions:
Notes:
Consent to Treat
This is to certify that on this date, as parent or guardian of this registered student, I give my consent to The Detroit
Hockey Academy and its medical representatives to obtain medical care from any licensed physician, hospital, or
clinic for the above mentioned participant, for any injury that could arise from participation.
_______________________________________
Parent or Guardian Signature
____________________________________
Date
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Detroit Hockey Academy
50950 Century Court
Wixom, MI 48393
(248) 926-5656
DetroitHockeyAcademy.com
Payment
The cost for the upcoming season is $12,000 per student.
Payment to occur as follows;
1. Payment of $2,000 USD is due upon initial sign up
2. Balance of payment can be handled in one of two ways;
a. Complete final payment of $10,000 USD due on or before September 1, 2015 - or b. Eight installment payments of $1,300 USD due the first of each month, starting with September
1, 2015 and ending on April 1, 2016.
i. The payment plan includes an additional service charge as well as interest
ii. The payment plan will be automatically charged on each due date via a provided credit
card through Member Solutions
Payment Plan Agreement
If you would like to utilize the payment plan process, please complete the following;
By this contract, I agree to make payments to Detroit Hockey Academy, hereafter known as “Lender,” by the above
schedule in exchange for admission to the Detroit Hockey Academy. This payment schedule is enforceable by law,
whereas any and all methods will be used to enforce the contract in cases of delinquent payment, as well as no
refunds, cancellations, or returns will be allowed for the period of the contract.
I fully understand and agree to the above payment plan terms.
_______________________________________
Parent or Guardian Name Printed
_______________________________________
Parent or Guardian Signature
____________________________________
Date
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Detroit Hockey Academy
50950 Century Court
Wixom, MI 48393
(248) 926-5656
DetroitHockeyAcademy.com
Media Consent and Release Form
As the parent or guardian of the student being registered, I hereby authorize the Detroit Hockey Academy, and
those acting in pursuant to its authority to:
1. Record students voice on video, audio, photographic, digital and electronic or any other medium
2. Use students name in connection with these recordings
3. Use, reproduce, exhibit or distribute in any medium (e.g. print publications, video tapes, CD-ROM,
Internet, social media) these recordings for any purpose that the Detroit Hockey Academy, and those
acting pursuant to its authority, deem appropriate, including promotional or advertising efforts
I release the Detroit Hockey Academy and those acting pursuant to its authority from liability for any violation of
any personal or proprietary right I may have in connection with such use. I understand that all such recordings, in
whatever medium, shall remain the property of the Detroit Hockey Academy.
I have read and fully understand the terms of this release.
_______________________________________
Parent or Guardian Name Printed
_______________________________________
Parent or Guardian Signature
____________________________________
Date
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Detroit Hockey Academy
50950 Century Court
Wixom, MI 48393
(248) 926-5656
DetroitHockeyAcademy.com
Waiver of Liability
This agreement releases Detroit Hockey Academy LLC / SJL Industries LLC (dba Puckmasters Detroit) / Legace
Hockey Academy LLC from all liability relating to injuries that may occur on the premises or during the act of
hockey training by Legace Hockey Academy for the Detroit Hockey Academy. By signing this agreement, I agree
to hold Detroit Hockey Academy LLC / SJL Industries LLC (dba Puckmasters Detroit) / Legace Hockey Academy
LLC entirely free from any liability, including financial responsibility for injuries incurred, regardless of whether
injuries are caused by negligence.
I also acknowledge the risks involved in hockey training and development. These include, but are not limited to,
bodily injuries, concussions, fractures, cuts, and in severe cases, death. I acknowledge that I am participating
voluntarily, and that all risks have been made clear to me. Additionally, I do not have any conditions that will
increase my likelihood of experiencing injuries while engaging in this activity.
By signing below I forfeit all rights to bring legal action against Detroit Hockey Academy LLC / SJL Industries LLC
(dba Puckmasters Detroit) / Legace Hockey Academy LLC for any reason. In return, I will receive participation in
the Detroit Hockey Academy based on the terms of this agreement. I will also make every effort to obey safety
precautions as listed in writing and as explained to me verbally. I will ask for clarification when needed.
I fully understand and agree to the above terms.
_______________________________________
Student Name Printed
_______________________________________
Student Signature
____________________________________
Date
I fully understand and agree to the above terms.
_______________________________________
Parent or Guardian Name Printed
_______________________________________
Parent or Guardian Signature
____________________________________
Date
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Detroit Hockey Academy
50950 Century Court
Wixom, MI 48393
(248) 926-5656
DetroitHockeyAcademy.com
Detroit Hockey Academy Administrative Use Only
Has the student enrolled in the Michigan Connections Academy?
Yes / No
If so, what is the student’s Client ID?
___________________
Is the student a Co-Op Student?
Yes / No
If so, do we have a copy of the student’s schedule on file?
Yes / No
How did student hear about Detroit Hockey Academy?
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Other Student
Coach
Web Search
Email Advertisement
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