USA/RS Roller Hockey League Registration Form

US on Wheels - 64th and Sheridan, Arvada, CO, 80003

Phone: (303) 423-0616 FAX: 303-423-1295

Winter Season Dates: December 31, 2009 - April 2010. Registration Deadline: January 10, 2010 ($10.00 late fee for registration after December 31, 2009)

Please Print! Once form is completed, form must be given to an employee at US on Wheels. Registration is not completed until all forms and fees are accounted for. Payment MUST accompany registration.

---

Player Name:______________________________,_________________________________,______

^{Last First M.I.}

Parent / Guardian Name(s):_____________________________________________________
Email Address:_____________________________________________________

Phone #: Home:(_____)___ ___ ___ - ___ ___ ___ ___ Work:(_____)___ ___ ___ - ___ ___ ___ ___
Address:____________________________ ____ ____________________________ ____ _______________

^{address apt.# city state zip code}

Age: _____ D.O.B.___ / ___ / ___ Social Security Number _____-____-__________

School: ________________________________________________________________

COPY OF BIRTH CERTIFICATE AND SOCIAL SECURITY NUMBER REQUIRED FOR NEW PLAYERS

Age Division Player Will Play In (circle one):

8&U / 9&10 / 11&12 / 13&14 / 15-19 / Girls / Adult:____________________________________________

--------------------------------------------------------------------------------------------------------------------------------

Return to Current Team: If you want to return to the team that you played on last season (last season only!),
please fill out the following. Note: Returning to the team is only guaranteed if form is turned in before announced deadline!

Team Played on:__________________________ Coach(s) of Team:_____________________________

---------------------------------------------------------------------------------------------------------------------------------

Requests: Please only request things that are absolutely necessary for player participation.

Note: REQUESTS ARE NOT GUARANTEED. INITIAL_______

Desired Team:___________________________ Desired Coach:__________________________________

Reason for Request (must fill out for consideration)____________________________________________

______________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------

OFFICE USE ONLY BELOW THIS LINE.__________________________________________________

Date Received: ____ / ____ / ____ Received by:__________________________________

Payment: Amount:$____________________ Type (circle one) Visa / M.C. / Cash / Check #________

------------------------------------------------------------------------------------------------------------------------------

q League Reg. Fee ($115.00 or $105.00) q Late Fee ($10) assessed December 31, 2009 or after. q Verify Age Division of Player (as of 1/1/10) q Entire Registration Complete q AAU Membership Application Complete q AAU Membership Payment ($14.00) q Copy of Birth Certificate Or q Previous USA/RS member q Social Security # q Guardian Signature on AAU Membership Application q Is Player a Goalie? Yes___ No___ q ____ Registration Posted in Book q ______ Registration Posted in Computer

Information to be Given: q Welcome & General Information Orientation / Coach / Parent Meetings q Parent Packet q Equipment Flyer Previous Experience/Notes: ____________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________