Roller Hockey Form

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Roller Hockey Begins Wednesday, September 3rd, 2014

for Boys & Girls of All Ages

Cost:  $30 for 6 week session.  You can pay by check the first day of the session.  Check will be made out to Chester Skateland and given to Judy Hoyle.  Cost will be $30 regardless on how many times you attend the 6 week session.

Location:  Chester Skateland

Contact Person:  Judy Hoyle

1. *

Parent Name:

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Home Phone Number:

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Cell Phone Number:

4. *

Home Address:

5. *


6. *

Zip Code:

7. *

Email Address:

8. *

Child's Name:

(A registration form must be filled out for each child)


Child's Age:

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 Group A 11:00 -­ 12:00 This group is for less experienced players, ones that may fall down easily and can not skate well.  Child can be any age.  Instruction is provided with game time. There is one coach and one assistant instructing the team. They begin with the basic skills of hockey.  Equipment Needed: hockey stick, knee pads, gloves and helmet, preferably with face guard, but bike helmet will do. NO child can play without a helmet. 

Group B 12:00 - 1:00  is for more experienced players.  Equipment Needed:  hockey stick, knee pads, elbow pads, gloves are required. Helmet MUST have a face guard (NO bike helmets are permitted).

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I hereby release Chester Skateland and any and all parties concerned with homeschool roller hockey from any liability resulting from injuries or damage during all sessions.

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12. *

Emergency Contact Person:

13. *

Emergency Contact Number:


Are you a member of the RollerHockeyVA yahoo group?

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