REGISTRATION

Complete the easy to follow, four (4) step online registration to reserve your place in the camp(s).

            1.  Complete the form below with all the appropriate information after reading Registration Policies.

            2. After the registration form has been completed, print the completed form for your records.

            3. After printing the form, click the "submit" button below.

            4. Finally, for camps, mail your $200.00 (check or money order) deposit to the following address:  

Mail Check or Money Order payments to:  Call 571-434-7466 to make payment using credit card.
Progressive Hockey Development 
c/o Darren Hersh
45524 Grand Central Square
Sterling, VA 20166

Note: Make checks payable to The Goalie Academy

Note: A 5% Convenience Fee applies to all credit payments

After we have received your $150.00 deposit, we will then send confirmation of your registration to you via email or postal service.  This confirmation will also include required insurance, medical and media forms.

Your $150.00 non-refundable* deposit is due 15 days from the date you submit this online registration form or your registration will be voided.

Wally Cup payments can be made at registration time on the day of the event.

REGISTRATION INFORMATION:

Registrant Name
Address
City/Town
Province/State
Postal Code/Zip Code
Country
Home Phone
Business Phone
Fax
email
Gender

Male  Female
Birthday/Age  Month     Day   Year     Age
Parent(s)/Guardian(s) Name(s)
Health Policy Company
Health Policy Number

INDICATE Camp/EVENT FOR WHICH YOU Are REGISTERING: 

 Select appropriate locations, dates, and times (You can only choose one event at a time):  

THE WALLY CUP!!!

THE WALLY CUP 3 on 3 Tournaments 2007 "Old School Pond Hockey" 

Fee is $40 per player or $280 per team (please register as a team 6 skaters + 1 goalie)  

WALLY CUP Squirt 1997/98 Birth Years Reston Skate Quest  December 26th 10:45am-12:45pm        

Enter Team Name and players:  Team Name   Players 1.

    2.    3. 4. 5.  

    6.   Goalie

 

WALLY CUP Pee Wee 1995/96 Birth Years Reston Skate Quest  December 26th 1:00pm-3:00pm        

Enter Team Name and players:  Team Name   Players 1.

    2.    3. 4. 5.  

    6.   Goalie

 

 

WALLY CUP Bantam 1993/94 Birth Years Reston Skate Quest  December 26th 3:15pm-5:15pm        

Enter Team Name and players:  Team Name   Players 1.

    2.    3. 4. 5.  

    6.   Goalie

 

PHD SYNTHETIC ICE PRIVATE LESSONS

 Progressive Hockey Development (Sterling, VA) LESSONS          Monthly Schedule Link

                 (Email Goalie_Academy@hockeymail.com with questions and to schedule a lesson) 

 

PLAYER EXPERIENCE: 

Current Level of Play    Age Level   

Position  Defense/Back   Forward/Up   Goalie

Years of Playing Experience

Current Team    

Coach's Name    Coach's Phone   

Coach's Email

ADDITIONAL INFO/COMMENTS:

Please use this additional space to send us any additional relevant information.

                 

               

(Required) Check if you have read,  have understood and agree to comply with Progressive Hockey Development's Registration Policies.