Parent/Guardian Name: Address: City: State: Zip code: Phone: Email: Participant Position: Skater Goalie Are you registering your child for an ALL GIRLS team? YES NO NOTE: A 2% cash discount will be applied to all fees if you pay via a checking or savings account. If you registered after the August 1 st early bird registration, the fees below (Remaining ) will be $150 more. Cost of the season in full will vary based upon the needs of your child (i.e. Jerseys/Jacket/Pants). Registration Deposit Paid Online - Skater Registration Deposit Paid Online - Goalie Jerseys/Jacket/Pants Remaining (Skater) Remaining (Goalie) Squirt (U10) $238 + Uniforms $119 + Uniforms $166/$61/$35 $2,152 $827 Peewee (U12) $238 + Uniforms $119 + Uniforms $166/$61/$35 $2,254 $877 Bantam (U14) $238 + Uniforms $119 + Uniforms $166/$61/$35 $2,305 $902.50 Midget (U16/U18) $238 + Uniforms $119 + Uniforms $166/$61/$35 $2,611 $1,055.50 Monthly Breakdown: Skater Monthly 3 Monthly 5 Squirt (U10) $2,152 $717.34 $430.40 Peewee (U12) $2,254 $751.34 $450.80 Bantam (U14) $2,305 $768.34 $461 Midget (U16/U18) $2,611 $870.34 $522.20 Monthly Breakdown: Goalie Monthly 3 Monthly 5 Squirt (U10) $827 $275.67 $165.40 Peewee (U12) $877 $292.34 $175.40 Bantam (U14) $902.50 $300.84 $180.50 Midget (U16/U18) $1,055.50 $351.84 $211.10 1
Please select one of the three payment options: Pay in Full One Payment in Full Funds will be automatically withdrawn from your credit card or checking account on September 29 th, 2017 Card holder Name: (print) Credit Card # Expiration Date: I hereby authorize the RecPlex and the financial institution designated above to automatically deduct from the account designated above for all participants listed on this form. I understand I will be charged on September 29 th, 2017. I understand my automatic deduction will occur on September 29 th, 2017, or up to 5 business days thereafter. I understand that my bank statement will typically show the amount and the date payment was made to the RecPlex if paying with a credit card, or VPP if I am paying via a checking account. I understand that I am responsible for ensuring that the account designated above has sufficient funds on September 29 th, 2017 or up to 5 business days thereafter, to allow for the automatic deduction of my payment. I understand that it is my responsibility to ensure the checking account # and routing # or credit card # are correct on this document and it is my responsibility to fill out a new form if I change financial institutions. I will notify the RecPlex Ice Arena Supervisor of any changes to my account information, in writing, 2 weeks prior to my monthly auto draft deduction. I understand I am liable for any uncollected payment and for any fees or penalties imposed by the RecPlex or my financial institution related to any uncollected payment. I understand that any declined payments are subject to a $25 NSF Fee. Account Holder s Signature: Date: 2
Payment Plan A 3 Monthly Installments (September, November, January) Funds will be automatically withdrawn from your credit card or checking account on the 3 rd Friday of each month Your first installment will take place on September 29 th, 2017 with all subsequent billings to occur on the 3 rd Friday of each month. Card holder Name: (print) Credit Card # Expiration Date: I hereby authorize the RecPlex and the financial institution designated above to begin automatic deductions from the account designated above for all participants listed on this form. I understand I will be charged monthly. My automatic deduction will occur on the 3 rd Friday of each month during the months designated above, or up to 5 business days thereafter. I understand that my monthly bank statement will typically show the amount and the date payment was made to the RecPlex, if I am pay via a credit card, or VPP if I am paying via a checking or savings account. I understand that I am responsible for ensuring that the account designated above has sufficient funds on the 3 rd Friday of each month designated above or up to 5 business days thereafter, to allow for the automatic deduction of my payment. I understand that it is my responsibility to ensure the checking account # and routing # or credit card # are correct on this document and it is my responsibility to fill out a new form if I change financial institutions. I will notify the RecPlex Ice Arena Supervisor of any changes to my account information, in writing, 2 weeks prior to my monthly auto draft deduction. I understand I am liable for any uncollected payment and for any fees or penalties imposed by the RecPlex or my financial institution related to any uncollected payment. I understand that declined payments are subject to a $25 NSF Fee. Account Holder s Signature: Date: 3
Payment Plan B 5 Monthly Installments (September January) Funds will be automatically withdrawn from your credit card or checking account on the 3 rd Friday of each month Your first installment will take place on September 29 th, 2017 with all subsequent billings to occur on the 3 rd Friday of each month. Card holder Name: (print) Credit Card # Expiration Date: I hereby authorize the RecPlex and the financial institution designated above to begin automatic deductions from the account designated above for all participants listed on this form. I understand I will be charged monthly. My automatic deduction will occur on the 3 rd Friday of each month, or up to 5 business days thereafter. I understand that my monthly bank statement will typically show the amount and the date payment was made to the RecPlex, if I am pay via a credit card, or VPP if I am paying via a checking or savings account. I understand that I am responsible for ensuring that the account designated above has sufficient funds on the 3 rd Friday of each month or up to 5 business days thereafter, to allow for the automatic deduction of my payment. I understand that it is my responsibility to ensure the checking account # and routing # or credit card # are correct on this document and it is my responsibility to fill out a new form if I change financial institutions. I will notify the RecPlex Ice Arena Supervisor of any changes to my account information, in writing, 2 weeks prior to my monthly auto draft deduction. I understand I am liable for any uncollected payment and for any fees or penalties imposed by the RecPlex or my financial institution related to any uncollected payment. I understand that any declined payments are subject to a $25 NSF Fee. Account Holder s Signature: Date: 4
Registration Agreement I agree to the policies and procedures set forth in the Vipers Hockey Club Fall League. I understand that while participating in the league the staff/referee is in charge. The Organization has my permission to use any photographs taken during the program for the purpose of display, publicity, or to post on social media. Emergency Treatment: I grant RecPlex and the Organization permission to administer emergency treatment. This may include, but is not limited to, emergency first aid, local rescue or local hospital/trauma center. Agreement: I understand that I am responsible for the payment(s) as indicated on the previous page. I understand I am liable for these charges even in the event that my child decides to quit mid-season. I understand that refunds are not given in the event that my child quits the team and leaves the organization mid-season. Payment: Payments are due as indicated on the payment authorization form. I agree to make payments to Village of Pleasant Prairie/RecPlex no later than the due date. I understand that declined payments are subject to a $25 NSF fee. Failure to make payment could result in suspension of the program. By completing and signing the registration form, I understand and agree to the terms, policies and guidelines set forth in the Vipers Hockey Club Policies. I agree to be responsible for all costs incurred with collecting debts more than 30 days past due, including but not limited to, fees for late payments, uncollected payments, filing fees, court costs, and attorney s fees. By signing below you understand and agree to Village of Pleasant Prairie/RecPlex payment terms and authorize Village of Pleasant Prairie/RecPlex to process your payments monthly. Village of Pleasant Prairie/RecPlex will securely maintain your financial information. Participants are responsible for updating with RecPlex any changes to your payment information, including credit card number; expiration date, credit card verification number, checking account information, and billing address changes. I have read and agree to the Vipers Hockey Club Program and Payment Policies. Parent/Guardian Name (Print): Signature: Date: 5