2018 FALL Roller Hockey registration ends on Wednesday, August 12, 2018. Click the link below for the registration form or register online below. 2018 Fall Hockey Participant’s Name:* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian:Email address:* Day Phone*Evening Phone*Date of Birth* Age as of March 28, 2018:*Current Grade in SchoolGender*MaleFemaleNote: Females are allowed to play down one full division if they choose. Number of Seasons Played:Interested in playing goalie?*NoYesSauk Valley Hockey provides goalie gear for all youth divisions. Your coach will have equipment available for practices and games. Player Divisions:*Roller Hockey 5—8 years Mite Division - $45Out of district Roller Hockey 5—8 years Mite Division - $55Roller Hockey 9—13 years Pee Wee Division - $45Out of district Roller Hockey 9—13 years Pee Wee Division - $55Roller Hockey 14—17 years Jr. High / High - $45Out of district Roller Hockey 14—17 years Jr. High / High - $55Roller Hockey 18 and up Big Guy - $70Out of district 18 and up Big Guy - $80A resident lives within the Park District boundaries, which include the Dixon city limits boundaries. Having a 61021 zip code does not necessarily qualify you as a Park District resident. Jersey Size*Youth (S-M) 34”-36”Youth (L-XL) 39”-40”Adult (S) 40”-42”Adult (M) 44”-48”Adult (L) 52”-54”Adult (XL) 54”-58”Adult (XXL) 58”-60”Goalie Cut 60”Jersey Number ChoicesJersey Number Choices: _______, _______, or _______Brother/Sister requests to play on same team:Sibling’s Name:Sibling’s age as of March 28, 2018:Any medical conditions that we should be aware of ?If yes, please list and submit a medical release from your physician by March 28 , 2018 to the Dixon Park District.I am interested in sponsorship!Name and Phone Number / Email Address to contact:Volunteering I am interested in volunteering for Coach (clinic required) I am interested in volunteering for Assistant I am interested in volunteering for Referee (clinic required) I am interested in volunteering for Scorekeeper / Announcer DIXON PARK DISTRICT WAIVER** For good and valuable consideration, the undersigned hereby releases the Dixon Park District; all of its cooperating agencies: and the elected commissioners, administrative officers, and instructors and agents of said parties, from any and all claims of whatever nature for any injury, loss, damage, accidents or expense arising from or out of the partici-pation in the Dixon Park District Recreation Program, and further agrees to indemnify and hold harmless all of said parties above enumerated against claims and for all costs and reasonable attorney’s fees arising out of or in any way connected to the participation in the recreation program. The undersigned hereby releases and agrees to indemnify and hold harmless all of said parties above in regards to person or persons the undersigned includes or invites to participate with them in any activity. Total $0.00 CAPTCHAPrivacy* By using this form you agree with the storage and handling of your data by this website.