2009/2010 ALASKA FIREBIRDS PLAYER REGISTRATION FORM

Please print this form, sign and return it to the Alaska Firebirds Organization P.O. Box 240802, Anchorage, AK 99524-0802 or your team manager. Payment can be made via the Paypal feature listing Payee as dlind@ceiak.com or by check to the Alaska Firebirds.

Registrant Information

Name:


First	Last

Address:

City, State Zip:

Phone:

Email:

TEAM REGISTERING FOR:

Player Date of Birth:

Other USA Hockey Registration:

If YES, Proide Association/Team Name:

Last Season Team/Association Name:

Position(s) Played:

Prior Hockey Experience (Years - Comp Hockey):

Prior Hockey Experience (Years - Rec Hockey):

Parent/Guardian 1 Name:

Home Phone - Parent 1:

Cell Phone - Parent 1:

Work Phone - Parent 1:

E-Mail - Parent 1:

Parent/Guardian 2 Name:

Home Phone - Parent 2:

Cell Phone - Parent 2:

Work Phone - Parent 2:

E-Mail - Parent 2:

Emergency Contact Name:

Emergency Contact Phone:

Comments:

REGISTRATION FEE

$285.00

U12-U19 Reg. Fee

For registration and payment in full before 5/31 - Check payment box below $260. IF PAYING BY CHECK (NO PAYPAL PAYMENT) YOU CAN DEDUCT $10 FROM THE LISTED PRICE.

$260.00

U12-U19 Reg. Fee Paid Prior to 5/31/08

IF PAYING BY CHECK OR CASH AND NOT UTILIZING THE PAYPAL FEATURE YOU MAY DEDUCT $10 FROM THE PACKAGE PRICE.

$235.00

U8-U10 Reg. Fee

For registration and payment in full before 5/31 - Check payment box below $210. IF PAYING BY CHECK OR CASH AND NOT UTILIZING THE PAYPAL FEATURE YOU CAN DEDUCT $10 FROM THE LISTED PACKAGE PRICE.

$210.00

U8-U10 Reg. Fee Paid Prior to 5/31/08

IF PAYING BY CHECK OR CASH AND NOT UTILIZING THE PAYPAL FEATURE YOU CAN DEDUCT $10 FROM THE LISTED PACKAGE PRICE.

$250.00

U19 Tier III

IF PAYING BY CHECK OR CASH AND NOT UTILIZING THE PAYPAL FEATURE YOU CAN DEDUCT $10 FROM THE LISTED PACKAGE PRICE.

I understand that participation in the Firebirds program is subject to the terms and conditions contasined in the Association Handbook, Alaska State Hockey Association Guidelines and the USA Hockey Annual Guide. I agree to participate in the Firebirds annual raffle and further agree to sell/purchase a minimum of 100 raffle tickets. Raffle proceeds are used to defray player expenses and help fund scholarships.

Relationship to Member:______________________________________

Signature:__________________________________________________

Date:________________________

PRIVACY STATEMENT
The Association may periodically release player names, addresses and phone numbers to USA Hockey sanctioned organizations, colleges, hockey schools and clinics for the purpose of providing additional opportunities for our Members, Sensitive personal information such as medical history, birth date, nationality, etc. WILL NOT BE RELEASED without prior written consent of a parent of guardian.

__________ PLEASE CHECK HERE IF YOU DO NOT WANT ANY CONTACT INFORMATION RELEASED.

I have read and agree to all terms and conditions above

Parent or Guardian Initials for Consent