Name

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Do you want to remain a member of your team from last season? *

Yes

No

Positions Played

Note: Reach out to Rick for additional goalie positions

Goalie

Forward

Defense

Payment Options - Early Bird option will expire on 8/30/2023 and the league price will increase to $600 *

All Credit Card Payments - Please use correct links on next page.

Early Bird Option $550 expries 8/30/2023

$600 on card one time payment

$525 Student Discount - must have valid student ID

Split Payment - $350 due now, $300 due by 1/1/2024

Player Sponsor (Contact us)

I agree to payment, all guidelines, rules, policies, and fees associated with the RVAHA season. I understand that there is a convenience fee for using a credit card at payment. I understand that I am responsible for all payments prior to the start of the season, or I may be removed from the league. I acknowledge that I have been provided with the rules and regulations as linked above, and agree to all the conditions outlined within. I acknowledge that I may need to sign further documentation and waivers. *

I Agree