HOCKEY 101
CONTACT INFORMATION
PLAYER’S NAME: ___________________________________________________
FIRST
DOB: _____/_____/_______
LAST
MM
DD
YYYY
USA HOCKEY NUMBER: _________________________________ OR □ EMAILED TO HOCKEY DEPARTMENT
BILLING ADDRESS: _______________________________________________________________________________
______________________________________________________________________________________
PARENT/GUARDIAN NAME: _________________________________________ RELATIONSHIP: ________________
PHONE: (_____) _______-___________
EMAIL: _____________________________________
PAYMENTS
REGISTRATION FEE - $50.00 This is a one-time fee for as long as the player is continuously enrolled in youth hockey
programming at Jacksonville Ice & Sportsplex. This fee does not qualify for discounts and is non-refundable.
TUITION - $100/month The first two months of tuition are charged at the time of registration. Following month 2, tuition
will be automatically withdrawn on the 1st of each month. Month 3 will reflect any proration that may apply.
DISCOUNTS □ MILITARY/FIRST RESPONDER - 10%
□ SIBLING – 10%
Discounts are applied at processing. Discounts cannot be combined and do not apply to Registration Fee.
ACKNOWLEDGEMENTS
Privacy Policy: The information provided above will be used solely by Jacksonville Ice & Sportsplex (“JIS”) for tracking
attendance, rewards, and marketing activities. This includes providing information to USA Hockey and the Tampa Bay Lightning
Made Hockey Programs. JIS does not sell or provide your information to any other organizations.
___________
Initials
I understand that: I must have a valid credit card on file, the card will be charged as outlined above, and
any declined payments must be brought current by the 5th of the month to avoid a $25 late fee.
___________
Initials
I hereby grant Jacksonville Ice & Sportsplex the absolute right and permission to publish, copyright, and
use pictures and/or video of the participant in which they may be included in whole or in part, composite,
or retouched, in character or form; without any monetary compensation or value received.
_______________________
Parent/Guardian Signature
_______________________
Print Name
FOR OFFICE USE ONLY
Received By: __________________
Date: __________
____
Date
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