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Player Last Name
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Player First Name
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Birth Date (mm/dd/yyyy)
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Height
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Weight
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Player (cell)
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Level played this year
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Position
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Forward
Defense
Goalie
Shoots
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Left
Right
Home Street Address
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City
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State
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Zip Code
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Parent Last Name
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Parent First Name
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Parent (home)
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Parent (cell)
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Parent Email
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Roommate Request
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I am registering for: (please check all sessions you would like to attend)
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Session 1: July 7 - 13
Session 2: July 14 - 20
Session 3: July 21 - 27
Session 4: July 28 - August 3
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Boarding: $1,199.00
Day: $975.00
Goalie (Boarding or Day): $699.00
Total Amount Due
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Payment Information
Payment
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Check
Credit card
If you wish to pay with a check, please mail to:
Shattuck-St. Mary's School
Attn: Boys Hockey Camps
P.O. Box 218
Faribault, MN 55021
*There will be an additional 2.85% processing fee
for credit card payments.
Credit Card Type
Visa
MasterCard
Discover
Name on Credit Card
Billing Address for Credit Card
Credit Card Number
Exp. Date (mm/yy)
CVC (3 or 4 digit code)
Please charge the following to my card:
Full amount
$300 deposit
Signature (I authorize SSM to charge my credit card the following amount chosen)
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I, as a parent or guardian of the above mentioned child, authorize him to take part in the Shattuck-St. Mary's Boys Elite Hockey Camp. I also authorize any emergency examination, x-ray, medical or surgical treatment deemed necessary by a licensed physician or hospital in Minnesota. I will not hold Shattuck-St. Mary's school, its coaches or staff responsible for accidents or injury that may occur while participating in any on or off-campus activities during his stay.
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To register, complete this form with a non-refundable deposit of $300 per player. The balance is due on or before June 1, 2019.
For more information, contact:
Jason Horstman '07, Director of Boys Summer Hockey
Phone: 1-507-333-1691
Email: jason.horstman@s-sm.org
For registration assistance contact:
Mary Hart, Registration
Phone: 1-507-333-1693
Fax: 507-333-1680
Email: mary.hart@s-sm.org
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