PARENT GUARDIAN INFORMATION
 
 
 
  
 
 
Parent/Guardian 1
 
  
 
 
First Name*
 
 
 
Last Name*
 
 
 
Phone*
 
 
 
Email Address*
 
 
 
  
 
 
Parent/Guardian 2
 
  
 
 
First Name
 
 
 
Last Name
 
 
 
Phone
 
 
 
Email
 
 
 
 
 
PARTICIPANT INFORMATION
 
 
 
  
 
 
First Name*
 
 
 
Last Name*
 
 
 
Birth Date*
 
 
 
Gender*
 
 
 
Address 1*
 
 
 
Address 2
 
 
 
City*
 
 
 
State*
 
 
 
Zip Code*
 
 
 
  
 
 
USA Hockey Confirmation # (14 digits - letters and numbers)*
 
 
 
  
 
 
The Penguins believe hockey is for everyone and the more diverse our sport is, the better off we’ll be. As this program specifically aims to increase diversity in our game, we’ve included the following question. Which of the following best represents the participant’s racial or ethnic heritage?
 
  
 
 
Select all that apply:
 
  
 
 
American Indian or Alaska Native
 
 
 
Asian
 
 
 
 
Black/African-American
 
 
 
Hispanic/Latinx
 
 
 
Middle Eastern or Northern African
 
 
 
Native Hawaiian or Other Pacific Islander
 
 
 
White/Caucasian
 
 
 
Other
 
 
 
 
If you answered "Other", please describe here:
 
 
 
 
 
 
 
 
 
Does the participant have any medical conditions, dietary restrictions, and/or allergies that we need to be aware of (asthma, diabetes, peanut allergy, etc)?*
 
 
 
If you answered "Yes", please describe here:
 
 
 
 
 
 
  
 
 
Player Position*
 
 
 
 
Current Association*
 
 
 
 
Current Team*
 
 
 
 
Coaches Name:
 
  
 
 
First Name*
 
 
Last Name*
 
 
 
Level of Team (Tier)*
 
 
 
 
Number of Years Played*
 
 
 
 
What other sports/activities do you participate in?*
 
 
 
As we continue to develop the curriculum, we would like to hear what players are looking to learn/develop/gain (on and off-ice) from participating.*
 
 
 
Did player participate in Little Penguins Learn to Play program?*
 
 
 
  
 
 
Player Apparel:
 
  
 
 
T-Shirt Size*
 
 
 
 
Jacket Size*
 
 
 
 
Warmup Pant/Short Size*
 
 
 
 
Practice Jersey Size*
 
 
 
 
  
 
 
Waiver(s):
 
 
  
 
 
I HAVE READ AND FULLY UNDERSTAND THIS ACKNOWLEDGEMENT, RELEASE, DISCHARGE AND INDEMNIFICATION. BY CLICKING “I ACCEPT THE TERMS OF THE WAIVER” I ACKNOWLEDGE AND AGREE THAT NO REPRESENTATIONS, STATEMENTS OR INDUCEMENTS HAVE BEEN MADE TO ENCOURAGE ME TO ENTER INTO THIS RELEASE AND THAT I AM DOING SO VOLUNTARILY. I FURTHER UNDERSTAND THAT CLICKING “I ACCEPT THE TERMS OF THE WAIVER” FUNCTIONS AS MY SIGNATURE TO SIGNIFY MY WILLING AGREEMENT TO THE TERMS OF THIS RELEASE.
 
  
 
 
UPMC Lemieux Sports Complex Waiver
 
 
 
Willie O'Ree Hockey Academy - Release Waiver