Inner-City Education Program Player Registration Form
We are excited for your player to participate in the ICE Program this season. Requirements include registration with USA Hockey, and acknowledgement of the waiver of liability, release, assumption of risk and indemnity agreement and the USA Hockey Concussion Information and Acknowledgement. Additionally, the publicity agreement and acknowledgement (photo release) must be signed/acknowledged below.

If you have more than one child playing with ICE, please fill out a form for EACH CHILD.

Email address *
At which rink does your child play? *
Publicity Agreement and Acknowledgement
The undersigned (“you”) hereby enters into this Publicity Agreement and Acknowledgment with Inner-City Education Program (“ICE”), an Illinois not-for-profit corporation.

For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

You hereby acknowledge, represent and warrant to ICE as follows:

In connection with ICE providing the child identified below (the “Child”) with certain scholastic and/or athletic opportunities, ICE may produce photographic images of the Child at various public events and/or athletic contests (“Photos”), at which time the Child will be under the age of eighteen (18);
you are either the legal parent or guardian of the Child; and you have the requisite legal power and authority and all necessary rights to execute this Agreement on behalf of yourself and Child, including the granting and assignment of all rights in the Photos to ICE, and the execution of this Agreement by you does not cause you to be in breach under any other agreement to which you are a party.

You acknowledge and agree that the above representations and warranties are necessary conditions for the Child’s participation in ICE program. Your representations and warranties will survive the termination of this Agreement.
You agree and acknowledge, on your behalf and on behalf of the Child, that ICE may use and/or release to third parties the Photos for ICE’s exempt purposes pursuant to its status under Section 501(c)(3) of the Internal Revenue Code, including without limitation ICE having permission to use, reproduce and distribute the Photos, videos and/or work product of the Child, without the need for compensation or future approval, for the purposes of marketing, education and fundraising through ICE’s marketing channels (including website, social media, electronic communications, television and print media).

You further consent to and agree that ICE and its affiliates may write about the Child (or quote you or the Child) for its publicity and other media purposes determined wholly within the discretion of ICE in any manner which furthers its exempt purposes pursuant to its status under Section 501(c)(3) of the Internal Revenue Code and as a not-for-profit corporation. You, on behalf of yourself and Child, grant ICE the irrevocable and worldwide right to use your and/or the Child’s name and/or likeness in any media, whether now known or later developed, in connection with the foregoing purpose as well as in connection with any publication or publicity of the Photos as ICE may choose to grant, in its sole discretion. You acknowledge and agree that nothing in this Agreement obligates ICE to use the Child’s or your name or likeness in any such respect. You expressly release ICE from any and all liability, expenses and costs resulting directly or indirectly from claims which you or the Child or any of your successors or heirs may have or bring for defamation, infringement of any personal publicity, privacy, or other proprietary right, any rights of paternity, integrity, disclosure and withdrawal and any other rights that may be known as "moral rights" or any other cause of action arising out of our use of your name and/or license or the name and/or likeness of the Child’s pursuant to this Agreement.
You agree to release, indemnify, defend, and hold harmless ICE and its respective officers, directors, employees and agents, and any of ICE’s contractors, sponsors and advertisers, from and against any and all claims, losses, demands, suits, costs (including reasonable attorneys’ fees), and other expenses arising directly or indirectly from any breach by you of any term or condition of this Agreement, including your representations and warranties. Your indemnification will survive the termination of this Agreement.

This Agreement has been executed in Illinois and shall be governed in accordance with the laws of the State of Illinois in every respect. The federal and state courts of Cook County, Illinois shall be the exclusive venue for any litigation, special proceeding or other proceeding between the parties hereto that may arise out of, or be brought in connection with or by reason of this Agreement.
The terms of this Agreement may be modified only by an agreement signed by you and an authorized officer of ICE. Any modifications made by you to this printed Agreement (whether handwritten or otherwise) will not be considered binding on ICE until you obtain written confirmation of such modification from ICE. Each party hereto may assign its rights, duties and obligations under this Agreement only with the written consent of the other party to this Agreement.
This Agreement represents the entire agreement between you and ICE with respect to the Photos and supersedes any and all prior agreements, understandings, negotiations, representations and discussions with respect thereto.
The parties agree that this Agreement may be executed in counterparts, each of which shall be an original and all of which shall constitute the Agreement, and that an electronic or facsimile copy of this Agreement with the signature of the parties shall be effective as original ink signatures for the purposes of the execution and delivery of this Agreement.

FOR THIS AGREEMENT TO BE BINDING, YOU MUST COMPLETE THE FOLLOWING:

FULL LEGAL FIRST Name of child: *
Your answer
FULL LEGAL LAST Name of child: *
Your answer
Player's Age *
Your answer
Player Date of Birth - mm/dd/yyyy *
Your answer
Player's Gender *
Player Citizenship:
Street Address *
Your answer
City *
Your answer
Zip code *
Your answer
Legal Parent FIRST Name *
Your answer
Legal Parent LAST Name *
Your answer
Cell Phone Number #1 (no dashes please) *
Your answer
Backup Phone Number #2
Your answer
Additional Parent/Family email:
Your answer
Additional Emergency Contact Name (other than parent/guardian): *
Your answer
Additional Emergency Contact Phone Number (other than parent/guardian): *
Your answer
As the National Governing Body of ice hockey, it is USA Hockey's mission to promote a "fun and learning" environment for the growth of the sport and all its participants. USA Hockey believes that hockey is for everyone and the more diverse our sport is, the better off we'll be. To help them more fully understand the make-up of our sport, please share with us which of the following best represents the player's racial or ethnic heritage?
IN WITNESS WHEREOF, the parties have caused this Agreement to be executed as of the submission date written of this Agreement. Please type your name as an electronic signature: *
Your answer
USA Hockey Registration
The ICE Program is a USA Hockey recognized hockey program. Therefore, all players must be registered with USA Hockey. By selecting "YES", I am giving the ICE Program permission to register my child with USA Hockey on my behalf.

Your child's name, birth date, address, gender and citizenship will be used. Parental names, addresses, phone numbers and emails will also be shared.

Regarding registering your child with USA Hockey: *
WAIVER OF LIABILITY, RELEASE, ASSUMPTION OF RISK & INDEMNITY AGREEMENT
IT IS THE PURPOSE OF THIS AGREEMENT FOR THE PARTICIPANT (AND PARTICIPANT'S PARENT(S)/GUARDIAN(S), IF APPLICABLE) TO EXEMPT, WAIVE AND RELIEVE RELEASEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, AND WRONGFUL DEATH, INCLUDING IF CAUSED BY NEGLIGENCE, INCLUDING THE NEGLIGENCE, IF ANY, OF ANY RELEASEES.
"Releasees" include USA Hockey, Inc., its affiliate associations, local associations, member teams, event hosts, other participants, coaches, officials, sponsors, advertisers, and each of them, their officers, directors, agents and employees.
For and in consideration of the undersigned Participant's registration with USA Hockey, Inc., its affiliates, local associations and member teams (all referred to together as USAH) and being allowed to participate in USAH events and member team activities, Participant (and the parent(s) or legal guardian(s) of Participant, if applicable) waives, releases and relinquishes any and all claims for liability and cause(s) of action, including for personal injury, property damage or wrongful death occurring to Participant, arising out of participation in USAH events, member team activities, the sport of ice hockey, and/or activities incidental thereto, whenever or however they occur and for such period said activities may continue, and by this agreement any such claims, rights, and causes of action that Participant (and Participant's parent(s) or legal guardian(s), if applicable) may have are hereby waived, released and relinquished, and Participant (and parent(s)/guardian(s), if applicable) does(do) so on behalf of my/our and Participant's heirs, executors, administrators and assigns.
Participant (and Participant's parent(s)/guardian(s), if applicable) acknowledges, understands and assumes all risks relating to ice hockey and any member team activities, and understands that ice hockey and member team activities involve risks to Participant's person including bodily injury, partial or total disability, paralysis and death, and damages which may arise therefrom and that I/we have full knowledge of said risks. These risks and dangers may be caused by the negligence of the Participant or the negligence of others, including the "Releasees" identified above. These risks and dangers include, but are not limited to, those arising from participating with bigger, faster and stronger participants, and these risks and dangers will increase if Participant participates in ice hockey and member team activities in an age group above that which Participant would normally participate in. Participant (and Participant's parent(s)/guardian(s), if applicable) further acknowledges that there may be risks and dangers not known to us or not reasonably foreseeable at this time. Participant (and Participant's parent(s)/guardian(s), if applicable) acknowledge, understand and agree that all of the risks and dangers described throughout this agreement, including those caused by the negligence of Participant and/or others, are included within the waiver, release and relinquishment described herein.
Participant (and participant's parent(s)/guardian(s), if applicable) acknowledges, understands and assumes the risks, if any, arising from the conditions and use of ice hockey rinks and related premises and acknowledges and understands that included within the scope of this waiver and release is any cause of action (including any cause of action based on negligence) arising from the performance, or failure to perform maintenance, inspection, supervision or control of said areas and for the failure to warn of dangerous conditions existing at said rinks, for negligent selection of certain Releasees, or negligent supervision or instruction by any Releasee.
As a condition of registration and membership in USA Hockey and participation in USAH events and member team activities, Participant (and Participant's parent(s)/guardian(s), if applicable) agrees to abide by and be bound under the playing rules and rules and regulations of USA Hockey, including the By-Laws of USA Hockey and the mandatory dispute resolution, discipline and arbitration provisions, as currently published in the USA Hockey Annual Guide. Copies of the USA Hockey Bylaws, including the mandatory dispute resolution, discipline and arbitration clauses, are available from the USA Hockey offices or may be found at www.usahockey.com/annualguide. Any dispute, claim or cause of action regarding the terms of this agreement or subject matter hereof shall be brought (i) individually, without resort to any form of class or collective action, and without joinder or consolidation of claims of third parties, and (ii) exclusively in the manner provided in the rules of USA Hockey (including, without limitation USA Hockey Bylaw 10) to the extent applicable.
As further consideration for registration and participation in USAH events and member team activities, Participant (and the parent(s) or legal guardian(s) of participant, if applicable), hereby (1) consents and agrees that USAH, its licensees and designees may make video and/or audio recordings of and/or otherwise film, photograph or memorialize some or all of Participant's participation in such events and activities, and (2) grants to USAH, its licensees, designees, successors and assigns, a worldwide, perpetual, irrevocable, fully-paid, royalty-free, transferable and sublicenseable right and license to use, copy and disseminate Participant's image and personal attributes, and to modify and present same in any form, manner and media, now known or hereafter devised, for any purpose whatsoever.
If the law in any controlling jurisdiction renders any part of this agreement unenforceable, the remainder of this agreement shall nevertheless remain enforceable to the full extent, if any, allowed by controlling law. This agreement affects your legal rights, and you may wish to consult an attorney concerning this agreement.
Participant (and Participant's parent(s)/guardian(s), if applicable) agree if any claim for Participant's personal injury or wrongful death is commenced against any Releasee, he/she shall defend, indemnify and save harmless Releasees from any and all claims or causes of action by whomever or wherever made or presented for Participant's personal injuries, property damage or wrongful death.
Participant (and Participant's parent(s)/guardian(s), if applicable) acknowledge that they have been provided and have read the above paragraphs and have not relied upon any representations of Releasees, that they are fully advised of the potential dangers of ice hockey, that they agree to and sign this document voluntarily, understanding that these waivers and releases are necessary to allow amateur ice hockey to exist in its present form. Significant exclusions may apply to USA Hockey's insurance policies, which could affect any coverage. For example, there is no liability coverage for claims of one player against another player. Read your brochure carefully and, if you have any questions, contact USA Hockey or a District Risk Manager.
Confirmation of the USA Hockey Waiver of Liability: *
Required
Type your initials here: *
Your answer
USA Hockey Concussion Information and Acknowledgement
USA Hockey Concussion Information and Acknowledgement
All sports and free play are associated with risk for a concussion, including playing, officiating or participating in ice hockey. It is important that all participants and parents learn about concussion prevention, recognition, treatment and return to play.
A concussion is a type of traumatic brain injury-or TBI- caused by a bump or blow to the head or by a hit to the body that causes the head and brain to move quickly back and forth. Bouncing or twisting of the brain in the skull can cause chemical changes and sometimes stretching of the brain cells. A concussion disrupts the way the brain normally works. Most concussions are mild, but all concussions should be taken seriously because permanent brain damage and death can occur from another injury. A concussion may be difficult to recognize. A player does not have to be "knocked-out" to have a concussion- less than 10% of players actually lose consciousness. Signs and symptoms may show up right after the injury or can take hours or days to fully appear.
If a person reports one or more symptoms or demonstrates any signs of concussion after a blow to the head or body, s/he should be kept out of practice, play or training immediately and referred to a health care professional with experience in concussion management. A concussed brain needs time to heal and the person is much more likely to have another concussion if they return to soon. Repeat concussions are usually more severe and take longer to heal. Return to play is allowed only after the individual is without symptoms, has progressed through the concussion protocol and is cleared by the health care professional.
USA Hockey provides all participants with information and educational materials about concussions, including the risk of sustaining a concussion, how to minimize these risks, concussion signs and symptoms, and USA Hockey's program for returning to play following a concussion.USA Hockey's Concussion Management Program can be found on the USA Hockey website at: http://www.usahockey.com/safety-concussions.
By checking the box and placing my initials in the box below, participant, and participant's parent(s) or legal guardian(s) if participant is a minor, hereby acknowledges (1) that I have had the opportunity to review information on concussions provided by USA Hockey, including the signs and symptoms of a concussion, (2) that participating in the sport of ice hockey involves the risk of sustaining a concussion and that I knowingly, freely and fully assume all such risks, (3) that any participant suspected of possibly sustaining a concussion will be removed from practice or competition (and that I will remove myself from practice or competition) and not returned to practice or competition until cleared in writing by a licensed health care provider trained in the evaluation and management of concussions, and (4) that I shall follow USA Hockey's Post-Concussion Return to Play Protocol and any applicable state law prior to returning to play.
Confirmation of the USA Hockey Concussion Information and Acknowledgement: *
Required
Type your initials here: *
Your answer
A copy of your responses will be emailed to the address you provided.
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