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CAPITAL CITY VIPERS
YOUTH HOCKEY CLUB, INC.
129 Litchfield Road, Harrisburg, PA 17112
dvhlcityvipers.pointstreaksites.com
2015-2016 PLAYER REGISTRATION FORM
Check Level:
o Mite
o Squirt
o PeeWee
o Bantam
o Midget 16
o Midget 18
1997 – 1998 = Midget 18
1999 – 2000 = Midget 16
2001 – 2002 = Bantam
2003 – 2004 = PeeWee
2005 – 2006 = Squirt
2007 & younger = Mite
Name:___________________________________________________________________________________________
(Last)
(First)
(Middle)
Address:_________________________________________________________________________________________
(Street)
________________________________________________________________________________________________
(City/State)
(Zip Code)
Home Phone:_____________________________________________________________________________________
Email address (father):______________________________________________________________________________
Email address (mother):_____________________________________________________________________________
Date of Birth: (mm/dd/yy)_____________________________________________
o Male
o Female
Father’s Name:_________________________________ Mother’s Name:____________________________________
Cell Phone #___________________________________ Cell Phone #_______________________________________
Previous Year Club & Level (Vipers or other):___________________________________________________________
# Years of Travel Hockey:________________
School District and 2015-16 Grade:____________________________________________________ _____________
I hereby acknowledge that I am registering to play for the Capital City Vipers Youth Hockey Club for the 2015
– 2016 season. I am not registered with another DVHL Club for this season and agree that I will be financially
committed to the Capital City Vipers.
I understand that, if payments are not made in full by October 31, 2015, my son/daughter will no longer be
able to play or practice until payment is current. If not paid in full by February 1st, the player’s name will be
placed on the AAHA financial list (according to AAHA Rule 17) and will not be able to play for the remainder of
the season.
_____________________________________________ __________________________________________________
PLAYER SIGNATURE
_____________________________________________
DATE
PARENT/GUARDIAN SIGNATURE
CAPITAL CITY VIPERS
YOUTH HOCKEY CLUB, INC.
129 Litchfield Road, Harrisburg, PA 17112
dvhlcityvipers.pointstreaksites.com
2015-2016 REGISTRATION FEES & PAYMENT POLICY
Season fees and payment schedule is as follows:
LEVEL
TOTALAPRIL MAY JUNE JULY AUG SEPT
MITE LIMITED TRAVEL
$600$100$250$250
MITE DVHL $800$100$250$250$250
SQUIRT
$1750$300*$300$300$300$300$300
PEEWEE
$1750$300*$300$300$300$300$300
PEEWEE AA $1950$300*$350$350$350$350$350
BANTAM
$1750$300*$300$300$300$300$300
MIDGET 16A & 18A$1750$300*$300$300$300$300$300
$470
$470
MIDGET 16AA $2600$300*
$470
* $50 non-refundable evaluation fee does not count toward season fees
** Squirt to Midget Goalies $1,100 **
Please make all checks payable to: Capital City Vipers Youth Hockey Club
For families with multiple children in our organization, a $200 discount will be given to the second child.
For payment made in full by May 31st, the Capital City Vipers will provide a $50 payment in full discount.
** Discounts do not apply to children at the Mite Level **
Current players must fulfill any outstanding financial obligation to the Capital City Vipers or any other DVHL
team before they are allowed to register.
Please complete the registration form and send it,
along with your check for the non-refundable
evaluation fee of $50 and 2015-16 USA Hockey
registration page to our Registrar:
Tonya Burd
Registrar, Capital City Vipers
1263 Hillside Drive
Mechanicsburg, PA 17055
Monthly Payments should be mailed to:
Lisa Kelly
Treasurer, Capital City Vipers
129 Llitchfiled Road
Harrisburg, PA 17112
All payments due at the end of every month.
CAPITAL CITY VIPERS 2015- 2016 PAYMENT POLICY
In an effort to ensure that the Viper organization maintains its financial stability, while maintaining a fun environment for the
families involved, the following is the Viper payment policy. Other payment arrangements can be made at the discretion of
the Board based on individual circumstances.
For non-payment: When a payment is 15 days late the parents will be notified that they have 15 days to become current
or their son/daughter will be suspended from further team activities until they are current with their financial responsibilities.
If they fail to make payment within 15 days, the player is suspended indefinitely from further team activities up to and
including practices and games. The player will not be reinstated until the family financial responsibilities have been met.
The coach of the respective team will be directed to not play that player or allow them to participate in any team activity
until that time.
CAPITAL CITY VIPERS
YOUTH HOCKEY CLUB, INC.
129 Litchfield Road, Harrisburg, PA 17112
dvhlcityvipers.pointstreaksites.com
2015-2016 Hockey Season
Player Name:_________________________________________________________________
Level:________________________________________________________________________
______ Vipers Registration Page
______ Proof of USA Hockey Registration 2015-16 Season
______ DVHL Code of Conduct 2015-16
______ DVHL Player/Parent Agreement Form 2015-16
______ USA Hockey Consent to Treat / Medical History Form
______ Copy of Birth Certificate (new players only)
______ $50 Evaluation Fee
check #_______
______ $250 Registration Fee
check #_______
All forms are required to be turned in at registration or your child
will not be permitted to take the ice for evaluations. No exceptions.