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MISSION HOCKEY DEVELOPMENT

Summer Program Registration

CHICAGO HOCKEY DEVELOPMENT

Summer Program Registration

"*" indicates required fields

Player Information

Player Name*

First Last

Players Email Address

Birth Date*

Month

Day

Year

Gender*

Male

Female

Age Group*

8 & Under (2018 & 2019)

10 & Under (2016 & 2017)

12 & Under (2014 & 2015)

14 & Under (2013 & & 2012)

Girls & Boys are Combined

Position*

Forward

Defense

FWD/DEF

Goal

Shot / Catch*

Left

Right

Camp Jersey Size*

Last Fall Season Team*

Tier*

AAA

AA*

Other*

*Acceptance Subject to review. If player is not accepted, a full refund will be issued.

Last Fall Season Coach*

Players Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

PARENT / GUARDIAN INFORMATION

Parent / Guardian #1*

Parent / Guardian #2

Email #1*

Email #2

Phone #1*

Phone #2

Code

Payment Information

Payment*

Full Payment ($1050)

Deposit ($150)

NOTE: If you pay with a $150 DEPOSIT, two equal payments of $450 they will AUTOMATICALLY be charged to your card on May 25th & June 25th.

Payment w/Discount*

Full Payment ($1050)

PAYMENT MUST BE "FULL PAYMENT" WHEN USING A DISCOUNT CODE

Referral*

Referral (-$100)

Limited Participation*

Limited Participation (-$300)

Half Off*

Half Off (-$525)

1 Week*

1 Week (-$735)

Payment Type*

Credit Card

Payment Amount(s)

Payment Amount

Price: $0.00

Installment Payment Amount (x2)

Price: $0.00

Credit Card

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

REFUND POLICY*

Mission Hockey Development: Program Fees are non-refundable.

I have read and acknowledge the refund policy

This field is hidden when viewing the form

2 Recurring Payments ($450/ea)

CAPTCHA

630-442-7234 • [email protected]

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