Sexsmith Minor Hockey Association REGISTRATION Box 322 Sexsmith, AB T0H 3C0 PLAYER APPLICATION FOR FORM PLAYER INFORMATION (PLEASE PRINT) LAST NAME FIRST NAME GENDER (CIRCLE) STREET ADDRESS ( PO BOX PLEASE) CITY/TOWN POSTAL CODE F M LEGAL LAND DESCRIPTION (IF APPLICABLE) HOME PHONE CELL PHONE DATE OF BIRTH / /. DD / MM / YYYY BIRTH CERTIFICATE # (NEW REGISTRANTS PROVIDE COPY) AB HEALTH CARE # (NEW REGISTRANTS PROVIDE COPY) TEAM INFORMATION (PLEASE PRINT) DIVISION PREVIOUS ASSOCIATION NUMBER OF YEARS PLAYING PREFERRED POSITION (CIRCLE) FORWARD / DEFENSE / GOAL SHOT (CIRCLE) PARENT / GUARDIAN INFORMATION (PLEASE PRINT) MOTHER S (GUARDIAN) NAME EMAIL ADDRESS R L MAILING ADDRESS CITY/TOWN POSTAL CODE HOME PHONE WORK PHONE CELL PHONE FATHER S (GUARDIAN) NAME EMAIL ADDRESS MAILING ADDRESS CITY/TOWN POSTAL CODE HOME PHONE WORK PHONE CELL PHONE SIBLINGS REGISTERED NAME DIVISION NAME DIVISION NAME DIVISION NAME DIVISION FOR REGISTRAR/TREASURER S USE ONLY AMOUNT REGISTRATION FEE Page 1 of 7 CASH CHEQUE # PAYMENT RECEIVED WITH REGISTRATION FOR: ADDITIONAL CHEQUE REQUIRED (ONE PER FAMILY) AMOUNT CHEQUE # Teepee Creek Rodeo, Casino & Bingo Bond Check $300.00 PAYMENT TYPE INSTALLMENTS CK# DATE: CK# DATE: CK# DATE: CK# DATE: KIDSPORT (ONLY PAYS $300/PLAYER) RESPECT IN SPORT?
Raffle & Road Side Cleanup Bond Check $150.00 I Agree to pay in lieu of volunteering REGISTRATION FEES DIVISION INITIATION VICE ATOM PEEWEE BANTAM MIDGET BIRTH YEAR 2010 2012 2008 2009 2006 2007 2004 2005 2002-2003 1999-2001 FEE $350.00 $425.00 $500.00 $560.00 $600.00 $625.00 There is a maximum family registration fee of $1200.00 for registered players from one immediate family. Payment for registration fees may be made in installments post dated and paid in full no later than December 31, 2016. A $25.00 NSF fee will be charged on all dishonored cheques. All previous fees and money owing to SMHA must be paid in full before player will be registered for upcoming hockey season. APPLICATION FOR REGISTRATION WAIVER I, the undersigned, certify the above information to be true and in consideration of the granting of this certificate to me with the privileges incident thereto, and by signing this certificate I have become subject to the rules, regulations and decisions of Hockey Alberta, its Board of Directors, its Minor Hockey Associations, Leagues, or Clubs which may be restrictive in some areas such as movement from team to team, conduct etc. and I agree to abide by such rules, regulations and decisions of Hockey Alberta, its Board of Directors, its Minor Hockey Associations, Leagues, or Clubs. Further, the information requested above is required by Hockey Alberta and its Minor Hockey Associations to facilitate hockey programs on behalf of the registrant, Hockey Alberta and its Minor Hockey Associations. All players and officials associated with Sexsmith Minor Hockey Association are covered by mandatory liability insurance through Hockey Alberta. This IS T an accident insurance policy. LIABILITY RELEASE: In consideration of the Sexsmith Minor Hockey Association (SMHA) accepting this application, I hereby waive and release any and all rights and claims for damages against SMHA for any and all injuries during any of the activities sanctioned by the Executive for the child(ren) named herein, his/her heirs, executors, and/or administrators. I accept full responsibility for the behavior of the child (ren) named herein on and off the ice. REGISTRATION will not be considered complete until all registration fees are paid in full (or acceptable installment arrangements have been made) and all additional cheque requirements are received by SMHA along with all documents including: registration form, player and parent code of conduct forms, parent declaration form, player verification (when required) form, and player medical form. All documents must be fully completed and signed by registrants and/or his or her parent(s) or guardian. A $25.00 fee will apply to any dishonored cheques. * PLAYER WILL BE ALLOWED ON THE ICE UNTIL FULLY REGISTERED WITH SMHA * Hockey Alberta and Sexsmith Minor Hockey will treat this personal information with the utmost respect and in accordance with the Hockey Alberta Privacy Policy and the Sexsmith Minor Hockey Privacy Policy at all times. Hockey Alberta or Sexsmith Minor Hockey does not sell trade or otherwise share the information we collect outside our Minor Hockey Associations, Affiliates, Leagues, or Clubs. However we may from time to time use this information for the purposes of offering additional services and/or hockey specific research. This type of usage of your child s personal information by Hockey Alberta, Minor Hockey Associations, Leagues, or Clubs is entirely at your discretion. There may from time to time be photos taken of your child for various League programs, the SMHA web site or for team advertisements under which only your child s name will appear. Should you choose to allow this type of usage please INITIAL the box here: [ ] [ ] For more information on Hockey Alberta s Privacy Policy please visit our web site at www.hockeyalberta.ca For more information on SMHA s Privacy Policy please visit our website at www.sexsmithminorhockey.com PARENT / GUARDIAN SIGNATURE Page 2 of 7
PARENT DECLARATION FORM TO: The Local Minor Hockey Association (c/o Registrar) in which the Player will be registering. DATE: Dear Sir / Madam: I/We parent(s) of player (Player s date of birth) / / hereby declare that I/we have Day Month Year established our permanent residence at the following address: Legal Land Description Postal Code Phone We have resided at the above address since /. Our former address was: Postal Code Phone Yours truly, Signature of Parent(s) *TE: Falsification of any information may result in discipline as per Hockey Canada regulations. Page 3 of 7
PARENT S PLEDGE It is the intention of this pledge to promote proper behavior and respect for all participants within the Association. All parents must sign this pledge before being allowed to participate in hockey and must continue to observe the principles of Fair Play. CODE OF CONDUCT FOR PARENTS 1. I will not force my child to participate in hockey. 2. I will remember that my child plays hockey for his or her enjoyment, not mine. 3. I will encourage my child to play by the rules and to resolve conflict without resorting to hostility or violence at all times, as I agree to resolve all disputes involving minor hockey without resorting to hostility or violence. 4. I will teach my child that doing one's best is as important as winning so that my child will never feel defeated by the outcome of the game. 5. I will make my child feel like a winner every time by offering praise for competing fairly and hard. 6. I will never ridicule or yell, or take physical action at my child/anyone else s child/ Coach/Parents or Officials for making a mistake or losing a game. 7. I will remember that children learn by example. I will applaud good plays and performances by both my child's team and their opponents. 8. I will never question the official's judgment or honesty in public. I recognize officials are being developed in the same manner as players. 9. I will support all efforts to remove verbal and physical abuse from children's hockey games. 10. I will show respect and appreciation for all volunteers who give their time to hockey for my child. I agree to abide by the principles of this CODE as set and supported by this Association. I also agree to abide by the rules, regulations and decisions as set for this Association. Page 4 of 7
PLAYERS PLEDGE It is the intention of this pledge to promote proper behavior and respect for all participants within the Association. All players must sign this pledge before being allowed to participate in hockey and must continue to observe the principles of Fair Play. CODE OF CONDUCT FOR PLAYERS 1. I will play hockey because I want to, not because others or coaches want me to. 2. I will play by the rules of hockey and in the spirit of the Game. 3. I will control my temper at all times - fighting or "mouthing-off" can spoil the activity of everyone. 4. I will respect my opponents. 5. I will do my best to be a true team player. 6. I will remember that winning isn't everything - having fun, improving skills, making friends and doing my best are important. 7. I will aspire to acknowledge all good plays and performances - those of my team and my opponents. 8. I will remember that coaches and officials are there to help me. I will accept their decisions and show them respect at all times. I agree to abide by the principles of this CODE as set and supported by this Association. I also agree to abide by the rules, regulations and decisions as set for this Association. PLAYER NAME (PRINT) PLAYER SIGNATURE DATE Page 5 of 7
SEXSMITH MIR HOCKEY ASSOCIATION MEDICAL FORM PLAYER INFORMATION (PLEASE PRINT) LAST NAME FIRST NAME GENDER (CIRCLE) STREET ADDRESS ( PO BOX PLEASE) CITY/TOWN POSTAL CODE MAILING ADDRESS (IF DIFFERENT THAN STREET ADDRESS) LEGAL LAND DESCRIPTION (IF APPLICABLE) DATE OF BIRTH HOME PHONE CELL PHONE AB HEALTH CARE # EMERGENCY CONTACT INFORMATION (PLEASE PRINT) LAST NAME FIRST NAME RELATIONSHIP TO PLAYER HOME PHONE WORK PHONE CELL PHONE FAMILY DOCTOR S NAME PHONE DATE OF LAST PHYSICAL FAMILY DENTIST S NAME PHONE PLEASE ADVISE YOUR COACH, TEAM MANAGER AND SMHA EXECUTIVE OF ANY HEALTH RESTRICTIONS 1. Have you ever been hospitalized?... Have you ever had surgery?... 1. Are you presently taking any medications or pills?... Are you presently taking any vitamins or supplements?... 2. Do you have any allergies? (medication, bees, etc)... If yes, please list: 3. Have you ever passed out during or after exercise?... Have you ever been dizzy during or after exercise?... Have you ever had chest pain during or after exercise?... Do you tire more quickly than your friends during exercise?... Have you ever had high blood pressure?... Have you ever been told that you have a heart murmur?... Have you ever had racing of your heart or skipped heartbeats?... Has anyone in your family died of heart problems or a sudden death before age 50?... 4. Do you have any skin problems (itching, rashes or acne)?... 5. Have you ever had heat or muscle cramps?... Have you ever been dizzy or passed out in the heat?... 6. Do you have trouble breathing or do you cough during or after activity?... 7. Do you use any special equipment (pads, braces, eye guards, etc)?... Do you use any dental appliances?... 8. Have you had any problems with your eyes or vision?... Do you wear eyeglasses, contacts or protective eye wear?... 9. Have you had any other medical problems (infectious mononucleosis, diabetes, etc.)?... 10. Have you had a medical problem or injury since your last medical?... 11. Have you had any unexplained weight change?... 12. When was your last tetanus shot? / / Month Day Year Page 6 of 7
13. When was your last measles immunization? / / Month Day Year HEAD INJURIES / CONCUSSION: 14. Have you ever had a seizure?... 15. Have you ever had a head injury?... Have you ever had a concussion or been knocked out, bell rung, or been dinged?... If yes, please list: Number of occurrences: Date(s): Activity a time of injury: Length of unconsciousness (minutes): Length of time before full return to activity: Did you have persistent problems with: Memory?... Dizziness?... Headaches?... NECK INJURIES / BURNERS / STINGERS: 16. Have you ever had a neck injury (i.e. strain, sprain, fracture, etc.)?... 17. Have you ever had a stinger, burner or pinched nerve?... Burning or numb feeling in the shoulder or arm after a hit to the head, neck or shoulder (aka Brachial plexus stretch injury ) If yes, please list: Number of occurrences: Date(s): Activity at time of injury: Length of sensation/strength changes persisted: Length of time before full return to activity: Check any of the areas that you have INJURED IN THE PAST and explain the injury below: Hand Hip Arm Ankle Elbow Shin/Calf Chest Forearm Neck Wrist Thigh Shoulder Year of injury: Type of injury: Side (Left/Right/Both): Length of time before full return to activity: Is it still a problem?... Back Knee Foot Explain injury: 18. Do you have any incompletely healed injuries?... If yes, which injury?... I hereby certify the above information to be correct. PLAYER NAME (PRINT) PLAYER SIGNATURE DATE Page 7 of 7