Parent's First Name: 

Parent's Last Name: 

Enter the name of the player in the fields below.
 

Player's First Name: 

Player's Last Name: 

You must choose a user name and password that you will use to login to your account through this web site in the future. When you have logged in you can see your currently scheduled sessions as well as enroll for future sessions.
 

Login User Name: 

Login Password: 

Location / Arena: 

Minnetonka – Pagel Activity Center Buffalo – Buffalo Civic Center Monticello – Moose Sherritt Arena Maple Grove – MGCC

Enter the following information about the player.
 

Date of Birth: 

January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Age Group / Level  
for 2010/2011 Season: 
 

Bantam Bantam Goalie HS Boys HS Boys Goalie HS Girls HS Girls Goalie Mite Pee Wee Pee Wee Goalie Squirt Squirt Goalie U10 / U12 U10 / U12 Goalie U14 U14 Goalie

Will this be your 1st, 2nd, 3rd,
or 4th year at this level? 
 

1st 2nd 3rd 4th

Position: 

Forward Defense Goalie

Address: 

City: 

State: 

Zip: 

Please make sure you enter a valid phone number and e-mail address since we use these methods to contact you regarding your account.
 

Phone: 

Alternate Phone: 

Email: 

List your preferred weeks here: 

Name On Credit Card: 

Type of Credit Card: 

VisaMaster Card

Credit Card Number: 

CVS Number (last 3 digits on back of card): 

Expiration Date: 

1234567891011122010201120122013201420152016201720182019

Please type in your 
payment amount here, 
along with any notes 
or comments: 

Make sure you have filled out all of the fields on this form. Only the Alternate Phone field is not required. Once all fields are filled out, click the "Click Here to Send" button below.

I acknowledge and understand that each player is voluntarily participating in activities that involve risk of injury which might result not only from their actions, inactions, or negligence, but the actions, inactions or negligence of others, the rules of play, the conditions of the premises, or any of the equipment used. This includes any risks not reasonably foreseeable to Impact Hockey, the Minnetonka Youth Hockey Association or Pagel Activity Center.

I assume the foregoing risks as a condition of participation and accept personal responsibility for the damages following any such injury.

I unconditionally release, waive, and consent not to sue Impact Hockey, the Minnetonka Youth Hockey Association, or Pagel Activity Center or its employees for any and all liability to the undersigned.

I hereby give permission of images of my child, captured during regular and special Impact activities through video, photo and digital camera to be used solely for the purposes of Impact Hockey promotional material and publications, and waive any rights of compensation or ownership thereto.

Check this checkbox to acknowledge that you understand and agree to the above conditions.