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MOON AREA HOCKEY ASSOCIATION
2015-2016
APPLICATION FOR MEMBERSHIP & REGISTRATION FORM
Player Name
Address
City / State / Zip
DOB
Grade 2015/2016
T-Shirt Size
Parent / Guardian
Phone:
Home
Cell
Home
Cell
Email
Address
City / State / Zip
Parent / Guardian
Phone:
Email
Address
City / State / Zip
Additional forms required at Application
Copy of Birth Certificate (for new players)
USA Hockey Registration (2015/2016)
USA Hockey Consent to Treat
USA Hockey Player Code of Conduct
Concussion Info Sheet & Acknowledgement
Media Release
MAHA Parent Code of Conduct
Jersey Number Selection
MAHA ONLY
IST CHOICE #
TRY-OUT FEE
2ND CHOICE #
COMMITMENT FEE
3RD CHOICE #
Try-out number
MAHA Tryout App 2015/2016
MAHA Received
Check #
Date
$75
$300
Page 1
TERMS OF APPLICATION FOR MEMBERSHIP, REGISTRATION AND COMMITMENT
1) I (we) agree to pay a non-refundable Try-out Fee for 2015-16 players of $75. In addition to the Try-out Fee, I
(we) agree to pay a $300 Commitment Fee. If the aforementioned fees are not paid, the player will not be
considered for placement.
a. Commitment fee fully refundable if;
i. A player chooses to decline his/her offered position prior to the deadline
ii. Is not offered a roster spot on any team.
b. Commitment fee is non-refundable if a player fails to decline his/her placement as required by the
specified date. Any unpaid dues would become immediately and fully due and payable.
c. The Registration/Tryout fee is Non-Refundable in any situation.
2) I (we) agree to pay all fees by the date due, as listed in the 2015–2016 fee schedules herein and
acknowledge that they are non-refundable and may not be waived. If a player withdraws from MAHA
membership or if membership is terminated for any reason, all fees paid are forfeited and payment of any
unpaid fees is accelerated and becomes immediately and fully due and payable.
3)
I (we) agree that I (we) are financially responsible for the purchase and maintenance of two (2) sets of
MAHA game jerseys and socks, (1-home, 1-away) and for the return and/or replacement and repair of any
equipment that may be assigned, which is lost, stolen or damaged beyond reasonable wear and tear in the
field of play.
4) Offer of Membership: By signing this document I (we) agree and understand that:
a. It does not constitute a guarantee of an offer of membership or placement;
b. Membership in the MAHA is a privilege and conditional upon an offer of membership and placement
extended by the MAHA within the sole discretion of the MAHA Board of Directors;
c. Placement of Players is made upon the recommendation of the MAHA ACE Coordinator and coaching
staff and
d. Players and Parents/Legal Guardians shall abide by all USA Hockey, MidAm, PIHL and MAHA policies,
rules and regulations, as well as satisfy all financial obligations.
5) In consideration of my participation and/or the participation of my child in the Pre-Season Player
Evaluations, I (WE) KNOWINGLY ASSUME ALL RISKS AND HAZARDS THEREOF, including, but not limited to
those known and/or unknown, foreseen and/or unforeseen. Further, I agree to release, defend, indemnify
and hold harmless the MAHA, its Board of Directors, Officers, agents, servants and all other
representatives and members, as well as USA HOCKEY, INC., from any and all liability, loss, expense,
attorney’s fees and claims for injury, death or damage which in anyway relate and/or refer to Participation
in Pre-Season Player Evaluations.
By our signature below we agree to be bound by all rules and regulations set forth by the
Moon Area Hockey Association and to uphold its by-laws at all times.
PLAYER NAME (Printed)
DATE
SIGNATURE
FATHER/LEGAL GUARDIAN (Printed)
DATE
SIGNATURE
MOTHER/LEGAL GUARDIAN
(Printed)
DATE
SIGNATURE
MAHA Tryout App 2015/2016
Page 2
Membership Fees for the 2015-2016 Season
Payments not received by the 15th of month due are subject to a $25 late fee.
Any account with 2 consecutive months’ payments outstanding will result in player(s) ineligibility for
participation in any manner until account is paid current.
Season fees are approximate and will be finalized after tryouts when rosters are determined and final budget is
approved.
The additional Varsity call up fee covers the extra practice afforded to those players. For Varsity call ups, there
is no guarantee of being called up to Varsity games.
Please Note: Based on the number of players available to each team, MAHA may split Middle School and Junior
Varsity teams into the main team and a practice squad or potentially a second team. If PIHL allows a second
team at these levels and MAHA declares the second team to play a PIHL schedule, the fees for the second team
would follow the fee schedule below. If MAHA creates a practice squad, those players would pay a reduced fee
based on their main team fee and would have the opportunity to participate in all practices at that level and, at
the discretion of the coaches, the potential to play in games.
LEVEL
MEMBERSHIP FEE
Varsity Team
$2,100 – $2,300
Junior Varsity Team*
$1,500 – $1,700
Middle School Team
$1,200 – $1,400
*Varsity call ups will incur an additional
$200 fee for the season.
The fee schedule below is just an approximation based on above price ranges. Final fee schedule will be
provided after tryouts when rosters are decided and a final budget is approved. The payment dates will not
change.
Junior Varsity
Commitment Fee
1st Installment
2nd Installment
3rd Installment
4th Installment
5th Installment
6th Installment
Due Date
At Tryout
7/1/2015
8/1/2015
9/1/2015
10/1/2015
11/1/2015
12/1/2015
Varsity
300
300 – 333.33
300 – 333.33
300 – 333.33
300 – 333.33
300 – 333.33
300 – 333.33
(Varsity call up)
300
233.33 – 266.66
233.33 – 266.66
233.33 – 266.66
233.33 – 266.66
233.33 – 266.66
233.33 – 266.66
Junior Varsity
300
200 – 233.33
200 – 233.33
200 – 233.33
200 – 233.33
200 – 233.33
200 – 233.33
Middle School
300
150 – 183.33
150 – 183.33
150 – 183.33
150 – 183.33
150 – 183.33
150 – 183.33
Fee Rebates/Discounts
Sibling Discount: A 10% per player discount will be applied for families w/ multiple MAHA players.
Goalie Discount: A 50% discount will be applied to all MAHA goalies. Goalies will be assessed the discount on the fee at
the level they are expected to play the majority of their games.
Note: Sibling/Goalie Discounts cannot be combined.
MAHA Tryout App 2015/2016
Page 3
Usa Hockey
Consent to treat/medical History form
This is to certify that on this date, I __________________________________________, as parent or
guardian of __________________________________________, (athlete participant), or for myself as an
adult participant, give my consent to USA Hockey and its medical representative to obtain medical
care from any licensed physician, hospital, or clinic for the above mentioned participant, for any injury
that could arise from participation in USA Hockey sanctioned events.
If said participant is covered by any insurance company, please complete the following:
Insurance Company: ___________________________________________________________
Policy Number: _______________________________________________________________
parent/Guardian/adult participant signature: _____________________________
date: __________
Excess accident insurance up to $50,000, subject to deductibles, exclusions and certain limitations,
is provided to all USA Hockey registered team participants. For further details visit usahockey.com or
contact USA Hockey at (719) 576-USAH.
emerGenCy ContaCt
Name: ___________________________________________________
Phone: _____________________
Address: _________________________________________________________________________________
Physician’s Name: ________________________________________
Phone: _____________________
Hospital of Choice: ________________________________________________________________________
Completion of mediCal History information Below is optional
mediCal History
If the answer to any of the following questions is yes, please describe the problem and its implications
for proper first aid treatment on the back of this form.
❑
Head Injury
(concussion, skull fracture)
❑
❑
❑
Fainting spells
Convulsions/epilepsy
Neck or back injury
❑
❑
❑
❑
❑
Asthma
High blood pressure
Kidney problems
Hernia
Heart murmur
❑
❑
❑
Allergies _________________
Diabetes
Other ____________________
_________________________
_________________________
Have you had (or do you currently have) any of the following?
Have you had a recent tetanus booster?
❑ Yes ❑ No If yes, when? _________________________
Are you currently taking any medications? ❑ Yes ❑ No If yes, please list all medications on back.
Has a doctor placed any restrictions on your activity? ❑ Yes ❑ No If yes, please explain on back.
3C rev 8/12
USA HOCKEY
PARTICIPANT
CODE OF CONDUCT
NAME:___________________________________________________
To be read and signed by you as a member of Team: ____________________
Participating in USA Hockey for the ____________ season.
1.
No swearing or abusive language on the bench, in the rink, or at any team
function.
2.
No lashing out at any official no matter what the call is. The coaching staff
will handle all matters pertaining to officiating.
3.
Anyone who receives a penalty will skate directly to the penalty box.
4.
Fighting will not be tolerated. Fighting will result in an appearance before a
Discipline Committee.
5.
There will be no drinking, smoking, chewing of tobacco or use of illegal
substance at any team function.
6.
I will conduct myself in a befitting manner at all facilities (ice rink, hotel,
restaurant, etc) during all team functions.
7.
Any player or team official who cannot abide by these rules or violates
them will be subject to further disciplinary action.
Signed: _______________________________ Date:___________________
Form 1-P Rev 02/09
Athlete/Parent/Guardian Concussion Information Sheet and
Acknowledgement Form
A concussion is a type of traumatic brain injury that disrupts normal functioning of the brain. . A
concussion can be caused by a bump, blow, or jolt to the head or body that causes the head
and brain to move rapidly back and forth. Concussions are a type of Traumatic Brain Injury
(TBI), which can range from mild to severe and can disrupt the way the brain normally functions.
Concussions can cause significant and sustained neuropsychological impairment affecting
problem solving, planning, memory, attention, concentration, and behavior.
The Centers for Disease Control and Prevention estimates that 300,000 concussions are
sustained during sports related activities annually and more than 62,000 concussions are
sustained each year in high school contact sports. Second-impact syndrome occurs when a
person sustains a second concussion while still experiencing symptoms of a previous
concussion. It can lead to severe impairment and even death of the victim.
The Safety in Youth Sports Act signed into law in November of 2011 mandates measures to be
taken in order to ensure the safety of student-athletes involved in interscholastic sports in
Pennsylvania. It is imperative that athletes, coaches, and parent/guardians are educated about
the nature and treatment of sports related concussions and other head injuries. The Act states
that:
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A student participating in or desiring to participate in an athletic activity and the student's
parent or guardian shall each school year, prior to participation by the student in an
athletic activity, sign and return to the student's school an acknowledgment of receipt
and review of a concussion and traumatic brain injury information sheet.
A school entity may hold an informational meeting prior to the start of each athletic
season for all ages of competitors regarding concussions and other head injuries, the
importance of proper concussion management and how preseason baseline
assessments can aid in the evaluation, management and recovery process.
In addition to students, parents, coaches and other school officials, the informational
meetings may include physicians, neuropsychologists, athletic trainers and physical
therapists.
A student who, as determined by a game official, coach from the student's team, certified
athletic trainer, licensed physician, licensed physical therapist or other official designated
by the student's school entity, exhibits signs or symptoms of a concussion or traumatic
brain injury while participating in an athletic activity shall be removed by the coach from
participation at that time.
The coach shall not return a student to participation until the student is evaluated and
cleared for return to participation in writing by an appropriate medical professional.
The governing body of a school entity may designate a specific person or persons, who
must be appropriate medical professionals, to provide written clearance for return to
participation.
In order to help determine whether a student is ready to return to participation, an
appropriate medical professional may consult any other licensed or certified medical
professionals.
Once each school year, a coach shall complete the concussion management
certification training course offered by the Centers for Disease Control and Prevention,
the National Federation of State High School Associations or another provider approved
by the Department of Health.
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A coach shall not coach an athletic activity until the coach completes a concussion
management certification training course.
The governing body of a school entity shall establish the penalties for a coach found in
violation of the requirements of removing a player or returning to play.
Quick facts
• Most concussions do not involve loss of consciousness.
• Athletes who have, at any point in their lives, had a concussion have an increased risk of
another concussion.
• Young children and teens are more likely to get a concussion and take longer to recover
than adults.
• You can sustain a concussion even if you do not hit your head.
• A blow elsewhere on the body can transmit an “impulsive” force to the brain and cause a
concussion.
• Signs and symptoms of a concussion can show up right after the injury or may not
appear or be noticed until days or weeks after the injury.
Danger signs
In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and
crowd the brain against the skull. An athlete should receive immediate medical attention if after
a bump, blow, or jolt to the head or body s/he exhibits any of the following danger signs:
• One pupil larger than the other.
• Is drowsy or cannot be awakened.
• A headache that not only does not diminish, but gets worse.
• Weakness, numbness, or decreased coordination.
• Repeated vomiting or nausea.
• Slurred speech.
• Convulsions or seizures.
• Cannot recognize people or places.
• Becomes increasingly confused, restless, or agitated.
• Has unusual behavior.
• Loses consciousness (even a brief loss of consciousness should be taken seriously).
Examples of signs of concussions observed by coaches, athletic trainers,
parents/guardians
• Appears dazed or stunned.
• Is confused about assignment or position.
• Forgets plays or demonstrates short term memory difficulties.
• Unsure of game, score, or opponent.
• Exhibits difficulties with balance, coordination, concentration, and attention.
• Answers questions slowly or inaccurately.
• Demonstrates mood, behavior or personality changes.
• Unable to recall events prior to or after the hit or fall.
Examples of symptoms of concussions reported by student-athletes
• Headache or “pressure” in head.
• Nausea/vomiting.
• Balance problems or dizziness.
• Double vision or changes in vision.
• Sensitivity to light and/or sound.
2
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Feeling sluggish, hazy, or foggy.
Difficulty with concentration and/or short term memory.
Confusion.
Just not “feeling right” or “feeling down.”
Why should a student-athlete report their symptoms?
• If an athlete has a concussion, his/her brain needs time to heal. While an athlete’s brain
is still healing, s/he is much more likely to have another concussion.
• Repeat concussions can increase the time it takes to recover.
• In rare cases, repeat concussions in young athletes can result in brain swelling or
permanent damage to their brain. They can even be fatal.
What should a student-athlete do if they think they have a concussion?
• Don’t hide it. Tell your Athletic Trainer, Coach, School Nurse, or Parent/Guardian.
• Report it. Don’t return to competition or practice with symptoms of a concussion or head
injury. The sooner you report it, the sooner you may return-to-play.
• Take time to recover. If you have a concussion your brain needs time to heal. While
your brain is healing you are much more likely to sustain a second concussion. Repeat
concussions can cause permanent brain injury.
What can happen if a student-athlete continues to play with a concussion or returns to
play to soon?
• Continuing to play with the signs and symptoms of a concussion leaves the studentathlete vulnerable to second impact syndrome.
• Second impact syndrome is when a student-athlete sustains a second concussion while
still having symptoms from a previous concussion or head injury.
• Second impact syndrome can lead to severe impairment and even death in extreme
cases.
What should you as a parent/guardian do if you think your athlete has a concussion?
• If you suspect that an athlete has a concussion notify the school and seek medical
attention.
• Do not try to judge the severity of the injury yourself.
• Keep your athlete out of play until a health care professional, experienced in evaluating
for concussions, says s/he is symptom-free and it’s OK to return to play.
• Rest is the key to helping an athlete recover from a concussion.
• Exercising or activities that involve a lot of concentration, such as studying, working on
the computer, or playing video games, may cause concussion symptoms to reappear or
get worse.
• Remember that after a concussion returning to sports and school is a gradual process
that should be carefully managed and monitored by a health care professional.
Should there be any temporary academic accommodations made for student-athletes
who have suffered a concussion?
• To recover cognitive rest is just as important as physical rest. Reading, texting, testingeven watching movies can slow down a student-athletes recovery.
• Stay home from school with minimal mental and social stimulation until all symptoms
have resolved.
• Students may need to take rest breaks, spend fewer hours at school, be given extra time
to complete assignments, as well as being offered other instructional strategies and
classroom accommodations.
3
Student-athletes who have sustained a concussion should complete a graduated returnto-play before they may resume competition or practice, according to the following
protocol:
• Step 1: Completion of a full day of normal cognitive activities (school day, studying for
tests, watching practice, interacting with peers) without reemergence of any signs or
symptoms. If no return of symptoms, next day advance.
• Step 2: Light Aerobic exercise, which includes walking, swimming, and stationary
cycling, keeping the intensity below 70% maximum heart rate. No resistance training.
The objective of this step is increased heart rate.
• Step 3: Sport-specific exercise including skating, and/or running: no head impact
activities. The objective of this step is to add movement.
• Step 4: Noncontact training drills (e.g. passing drills). Student-athlete may initiate
resistance training.
• Step 5: Following medical clearance (consultation between school health care personnel
and student-athlete’s physician), participation in normal training activities. The objective
of this step is to restore confidence and assess functional skills by coaching and medical
staff.
• Step 6: Return to play involving normal exertion or game activity.
Remember
Concussions affect people differently. While most athletes with a concussion recover quickly
and fully, some will have symptoms that last for days, or even weeks. A more serious
concussion can last for months or longer. It’s better to miss one game than the whole season
For more information on Sports-Related Concussions and other Head Injuries, please visit the
following websites:
www.cdc.gov/concussion
www.gopats.org
www.biapa.org
www.brainsteps.net
www.stopsportsinjuries.org/concussion
www.ncaa.org/health-safety
www.concussionwise.com/pennsylvania
http://www.portal.state.pa.us/portal/server.pt/community/grants___funding/14140/traumatic_brai
n_injury/666239
_____________________________
Signature of Student-Athlete
_____________________________
Signature of Parent/Guardian
__________________________
___________
Print Student-Athlete’s Name
Date
_________________________
Print Parent/Guardian’s Name
__________
Date
References:
1. The Centers for Disease Control and Prevention (CDC): “Heads Up Tool Kit for Youth Sports”
2. NCAA: “Concussion- A Fact Sheet for Student-Athletes”
4
Moon Area Hockey Association
Media Release Form for Minor Children
Please provide all the information asked for below.
Player Name: ______________________________________________________________________
Parent/Guardian’s Name: _____________________________________________________________
Home address:______________________________________________________________________
I, Parent/Legal Guardian of (player’s name) _________________________ hereby grants permission to
Moon Area Hockey Association, its agents and assigns, to use above named child’s photo or video, and
likeness for the purpose of promotion by Moon Area Hockey Association for all forms, media and
manners, for the following, but not limited to, news releases, photographs, video, audio, website,
marketing, advertising, trade, promotion, exhibition for an indefinite period of time.
I give unrestricted permission for images, videos, and recordings of the player to be used in print, video,
digital and internet media. I agree that these images and/or voice recordings may be used for a variety of
purposes and that the images may be used without further notifying me.
I further acknowledge that I will not be compensated for these uses and the Moon Area Hockey
Association owns all rights to the images, videos, and recordings, and to any derivative works created
from them.
I waive any right to inspect the uses of any printed or electronic copy. I hereby release Moon Area
Hockey Association and its agents and assigns from any claims that may arise from these uses, including
without limitation claims of defamation or invasion of privacy, or of infringement of moral rights or rights of
publicity or copyright.
This Release expresses the complete understanding of the parties.
Signed (Parent/Gurardian): ____________________________________________________________
Printed Name:_______________________________________________________________________
Date: _______________________________
PARENT’S CODE OF CONDUCT
It is the intention of this compact to promote Fair Play and Respect for all Participants within USA Hockey. It is expected
that all parents of USA Hockey participants read and understand the Parent’s Code of Conduct and continue to observe
and follow all the principles contained within the Code throughout the year.
1. I will not force, ridicule, or yell at my child to participate in hockey. I will try to make it FUN!
2. I will encourage my child to play by the rules and to resolve conflict without resorting to hostility or violence.
3. I will teach my child that doing one’s best is as important as winning so that my child will never feel defeated by the
outcome of the game. I will make my child feel like a winner every time by offering praise for competing fairly and hard.
4. I will remember that children learn by example. I will applaud good plays by both my child’s team and their opponents. I
will not be critical of, or embarrass any player, including opposition players.
5. I will never question the official’s judgment or honesty in public. I recognize that officials are being developed in the
same manner as players.
6. I will respect and show appreciation for the volunteers who give their time to hockey for my child.
7. I will never yell, taunt, threaten or inflict physical violence upon any player, coach, official or spectator at any youth
hockey event. I will refrain from the use of abusive or vulgar language, racial, ethnic or gender-related slurs at any time
at the rink or any youth hockey function. I will support all efforts to remove verbal and physical abuse from youth hockey
games. I will not throw objects on the ice, lean or pound on the glass.
8. I will leave the coaching to the coaching staff. I will encourage my child to play in a manner consistent with the team’s
strategy or plans.
9. I will support the coaches emphasizing skill development and a serious commitment to practices.
10. I will attempt to learn about the game of hockey (USA Hockey rules, equipment, levels, skills, etc.) so that I may best
support my child’s development in the game.
11. I will insist that my child plays in a safe and healthy environment. I will support a sports environment that is free of
alcohol, drugs or tobacco and I will refrain from their use at all youth sports events.
12. I understand the benefits from participating in a team sport, the commitment, the discipline and the social skills
learned and acquired.
13. I will remember that my child plays hockey for his or her enjoyment, not mine.
14. I will communicate all and any concerns regarding inappropriate behavior to the Team Manager, Coaching Director,
ACE(Association Coaching Education) or association President. Any behavior or action deemed inappropriate that
leads to the embarrassment of any player, coach, official, or association is to be reported immediately.
a. 24 hour rule is in affect
b. Email is to be sent to the team manager
c. Team manager will forward the complaint to the Ace Coordinator and the Association President
d. Complaint/issue will be responded to within 7 days
I have read and understand the above Code of Conduct, and agree to abide by its guidelines at all team and
league activities. I understand that if I do not follow this Code of Conduct, I may be asked to leave the league
activity (such as a game or practice or suspended from an activity)
Parent Name: ___________________________________________________ Date: __________________
Parent Signature: _______________________________________________________________________
Parent Name: ___________________________________________________ Date: __________________
Parent Signature: _______________________________________________________________________
Player’s Name __________________________________________________ Team: __________________