Mt. Lebanon High School Hockey Association
2012-2013 Registration Form
Address________________________________________ Zip Code_______________
Phone #______________________ E-mail(s)__________________________________
Parent / Guardian Names_________________________________________________
Date of Birth______________ 2012 - 2013 team(s) _____________________________
Grade entering Height Weight_________________
How many years of Amateur Hockey experience do you have? __________________
Will you be playing on an Amateur Hockey Team for the 2011-2012 Season? _______
Are you registered with USA hockey for the 2012 - 2013 Season? YES I NO
I, the undersigned parent/guardian of the above named minor child, agree to assume
all risks and hazards incidental to players participating in the MLHSHA 2011 - 2012
program, including games, practices, and off ice conditioning, as well as travel to and
from such activities, and I do hereby release, absolve, indemnify, and hold harmless
MLHSHA, its Officers, Directors, Members, Managers, Coaches, Rink Personnel,
Referees, Supervisors, Players and any other persons authorized by MLHSHA to act
in connection with this program for any damages arising out of injuries to the player.
I consent to, and the player is authorized, to participate in all phases of the program.
I also agree to, and understand that the MLHSHA Organization has a No Refund
Policy. I am responsible for all dues in full, even if the player is unable to participate
due to illness or injury, team removal, or voluntary withdrawal.
Date Parent / Guardian
I assume full responsibility for all equipment and uniforms issued to me by MLHSHA. I
agree to use my MLHSHA uniform for game competition only, not to wear it at other
times, and return it, if applicable, to MLHSHA in a timely manner.
I understand that as a member of MLHSHA, I am representing the Association, The
Mt. Lebanon School District, and all of its standards and ideals. Any unworthy action
on my part could result in suspension and/or permanent separation from the