Pleasant Prairie Patriots House Hockey

Pleasant Prairie Patriots House Hockey 2012-2013 Registration Packet Hockey@plprairie.com www.recplexonline.com/sports/hockey Ice Arena Front Desk: 262-925-6755 Hockey Director: 262-925-6572 Pro Shop: 262-925-6758

USA HOCKEY CONSENT TO TREAT 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: Name of Insurance Company: Address: Policy Number: Signed: (parent/guardian or adult participant) Relationship to Athlete: Home Address: Phone: ( ) 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 www.usahockey.com or call USA Hockey at 719-576-USAH. (over, please) 3C Rev 3/04

MEDICAL HISTORY FORM (COMPLETION OF THIS SIDE OF THE FORM IS OPTIONAL) Name Date: Address: Birthdate: Daytime Phone: Evening Phone: WHO TO CONTACT IN CASE OF AN EMERGENCY? Name: Relationship: Daytime Phone: Evening Phone: Physician's Name: Daytime Phone: Evening Phone: Hospital of Choice: PLEASE COMPLETE THE FOLLOWING: If the answer to any of the following questions is or was yes, please describe the problem and its implications for proper first aid treatment on a separate piece of paper. Have you had (or do you presently have) any of the following? Circle One Head injury (concussion, skull fracture) Yes No Fainting spells Yes No Convulsions/epilepsy Yes No Neck or back injury Yes No Asthma Yes No High blood pressure Yes No Kidney problems Yes No Hernia Yes No Diabetes Yes No Heart murmur Yes No Allergies Yes No Please specify: Injuries to: Shoulder Yes No Knee Yes No Ankle Yes No Fingers Yes No Arm Yes No Other: Impaired vision Yes No Impaired hearing Yes No Other: Have you had a recent tetanus booster? If so, when? Are you currently taking any medications? What? Why? Has the doctor placed any restrictions on your activity? Explain: 3C Rev 3/04

How to Complete USA Hockey Registration Prior to the 2012-13 season all participants must complete the USA Hockey Registration process. USA Hockey requires that all players register directly on their website. In addition, we are required to provide each player s USA Hockey confirmation number when we submit our team rosters. It is critical that each parent provide us with those numbers in order to properly register the team with USA Hockey. Below are the directions on how to register. We tried to simplify them as much as possible. 1. Go to http://www.usahockeyregistration.com/ 2. Click on Ice Players and Coaches 3. Click on the checkbox that indicates you are 18 years or older and then click Continue 4. Click Continue on the 2012-13 Season. 5. Click on a Child Family Member and then click Continue 6. Complete the Participant Information form and click Continue to Checkout 7. If you have another child to register click on Register Someone Else and repeat steps 2 through 6. If this is your last child continue to step 8. 8. Click the confirmation checkbox(s) and then click on Continue 9. Enter your billing information and click Pay Now. Your bill should equal $35 times the number of players you registered. 10. You should receive an email (one per child) with your USA Hockey Confirmation Number almost immediately. If you are not sure if you received the email just go ahead and print the confirmation numbers from the Registration Confirmation page. 11. Retain a copy of the confirmation number(s) and return with the completed parent packet. We need those numbers to register our teams with USA Hockey.

Pleasant Prairie Patriots Player Code of Conduct PLAYERS CODE I will play for fun, work hard to improve my skills, be a team player, and get along with my teammates. I will demonstrate teamwork, sportsmanship, and discipline. I will be on time for practices and games, learn and abide by the rules and always be a good sport. I will respect coaches, managers, officials, teammates, parents, and opponents. I will respect the property of others including, but not limited to teammates, coaches, opponents, the RecPlex Ice Arena and Prairie Springs Park. I will not openly and unreasonably dispute or argue an official s decision. I will never use disrespectful, abusive, or obscene language to coaches, managers, parents, teammates or opponents. I will not use illegal drugs or alcohol at any time. I understand that doing so will result in the immediate dismissal from the team. In addition to any penalties assessed during the game, any violation of the above Players Code may result in a one game suspension. A second violation may result in a two game suspension. Any additional violations may result in a season suspension. Agreement and Affirmation by Player As a Player, I have read the foregoing Code of Conduct. I agree to be bound by the foregoing Code of Conduct and I understand the responsibilities and consequences if I fail to adhere to the Code. Player s Signature: Date: Parent s Signature: Date:

Pleasant Prairie Patriots Parent Code of Conduct PARENTS CODE I will display good sportsmanship, and always respect players, coaches, managers, officials and other parents. I will act appropriately at all times, cheer for good plays of all participants in a positive manner, and encourage fair play. I will be supportive after the game, win or lose, and I will recognize good effort, teamwork and sportsmanship. I will resolve to conduct myself as a parent and an adult even under the most trying circumstances. I will not use obscene or vulgar language or act in a boisterous manner to anyone at any time at the rink, before, during or after a game. I will not taunt players, coaches, managers, officials, or other spectators by means of baiting, ridiculing, threat of physical violence or actual physical violence. I will not throw any items on the ice surface, spectator viewing areas, player s bench, or penalty box. I will not boo players or officials. I will not openly object to an official s call or yell at an official. I will not lean over or pound on the rink glass. I will not embarrass my child by yelling at players, coaches, managers, officials, or other parents and I will always show a positive attitude toward the game and all of the participants. For the initial violation of the Parents Code, the parent may not be allowed to attend any games or practices for a period of up to 30 days. For any additional violation, the parent is subject to further disciplinary action by the Hockey Direction, which may include a permanent ban on attending Patriots functions OR suspension of the child for the parent s failure to adhere to the Code. Agreement and Affirmation by Player As a Parent, I have read the foregoing Code of Conduct. I agree to be bound by the foregoing Code of Conduct and I understand the responsibilities and consequences if I fail to adhere to the Code. Parent s Signature: Date: Parent s Signature: Date:

Pleasant Prairie Patriots House Hockey Waiver & Emergency Treatment Release Form Emergency Treatment Form I,, hereby authorize any physician and/or any member of the medical staff of any hospital or emergency treatment center to render medical treatment (parents are responsible for all medical expenses incurred), which in his or her judgment may be deemed necessary in the care of: Skaters Name: Date of Birth: Physician s Name: Physician s Phone Number: Allergies: Current Medications (if applicable please request medication form): Outstanding Medical History: Insurance Company: Membership Number: Emergency Contact #1: Phone: Cell: Emergency Contact #2: Phone: Cell: Parent or Guardian s Signature (if under 18): Date: Publicity: Periodically photographs and videos are taken of Patriots Hockey Participants. They are used for newspaper stories, educational purposes or for RecPlex publications. I hereby grant permission to RecPlex to use any/all photos or video taken at such times. (initial) Liability: I do hereby agree to hold free from any and all liability the Village of Pleasant Prairie including RecPlex and Ice Arena and its officers, employees and administrators, waive, release or forever discharge any and all rights and claims for damages which I may have or which I may accrue to me arising out of or connected with my child s participation in any of the activities. (initial) Permissions: If my child is transported via our Rescue Squad, please circle the hospital you would want to be transported to: St. Catherine s Hospital (nearest to RecPlex) Aurora Medical Center Kenosha Hospital I attest that the health information given is complete and correct and the child has permission to participate at his/her own risk in Patriots Hockey activities unless notified. I attest that my child s immunizations are current and comply with today s standards. I declare my child to be physically sound, having medical approval to participate in the activities of the Patriots Hockey program. This release form is completed and signed of my own free will and with sole purpose of authorizing medical treatment under emergency circumstances in my absence. I acknowledge that I am releasing my child/ward into the care of the RecPlex/Ice Arena and that the information above will be used to provide the best possible care for him/her. I also acknowledge that the Ice Arena coaches/staff will make the best choice in terms of care for my child in my place. I do acknowledge that RecPlex/Ice Arena reserves the right to terminate enrollment if my child s behavior warrants dismissal. Signature: Date:

Pleasant Prairie Patriots 2012-2013 Registration Form Player's Name - Member / Non-member (Circle) Birth Date Last First MI Month Day 19xx USA Hockey Membership # (See Attached Sheet) Team and Level Played Last Season Skater / Goalie Circle both if willing to try goalie Goaltenders receive a $150 discount if they supply their own equipment. If no one commits to playing goalie, kids will rotate through the position Parent / Guardian #1 Parent / Guardian #2 Address Address City State Zip City State Zip Home Phone: Cell Phone: Email: Home Phone: Cell Phone: Email: Registration available on a first come first serve basis. A $100 commitment fee (non-refundable but applicable toward season fees) will be due at the time of registration. In the event a child cannot be placed on a team, the commitment fee will be refunded. 50% of the remaining balance will be due October 1, 2012 and the rest is due December 1, 2012. Make checks payable to Village of Pleasant Prairie. Visa, Mastercard, and Discover credit cards are accepted.