EXPLOITS VALLEY MINOR HOCKEY ASSOCIATION

REGISTRATION FORM

MALE:____________ FEMALE:________ DIVISION:_______________________

CHILD’S NAME: _______________________________________________________

DATE OF BIRTH: ______________________________________________________

MCP#: _______________________________________________________________

ADDRESS: ___________________________________________________________

__________________________________________________________

E-MAIL ___________________________________________________________

TELEPHONE: HOME: __________________ WORK: _______________________

PARENTS/GUARDIAN: _________________________________________________

_______________________________________________

DOES YOUR CHILD HAVE ANY MEDICAL CONDITION THAT THE COACHING STAFF SHOULD BE MADE AWARE OF?____________________________________

All Players from Initiation to Midget MUST wear certified mouth guards.

BIRTH CERTIFICATES REQUIRED FOR NEW/FIRST TIME PLAYERS

PARENTS/GUARDIAN SIGNATURE: _______________________________________

DATE: _______________________________________

METHOD OF PAYMENT: (# OF CHILDREN REGISTERING _________)

FIRST TIME REGISTRATION: YES_____ NO _________

HNL INSURANCE FEE:_______________ PAID:_______ REC#

(CASH/CHEQUE)

REGISTRATION FEE: ________________ POST-DATED CHEQUE______

DATE AMT CHEQ#

TOTAL DUE: ___________________ ______ ______ ______

______ ______ ______

YOU ARE ENCOURAGED TO BECOME A VOLUNTEER

**REGISTRATION DUE IN FULL BY JANUARY 1st OR ICE -TIME WILL BE DENIED.