Corporate: Kroger Kid Starter

Parent/Guardian Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Email*

Name of Child*

First Name

Last Name

Age of Child*

Youth Hockey Association

Youth Hockey Team Name

Skill level:*

House Travel

Position:*

Player Goaltender

How many years have you played on an organized hockey team?

USA Hockey 2018-19 Membership Number

Can’t find your confirmation #? Visit usahockeyregistration.com and click on link for “Request Duplicate Registration Confirmation”

Coach Name

First Name

Last Name

Coach Phone

Are you under the age of 18?*

Yes No