Leading Edge Hockey: Application Form

 

Program
__________________________________________________  
Name
__________________________    
Address
__________________________________________________
City
__________________________
Postal Code
__________
Phone
__________________________
Age (as of Dec 31/06)
_______
Email address
__________________________
 
Playing experience (yrs)
__________
Division
__________

T Shirt size
(circle one)

Youth:   L    XL        Adult:  S    M    L    XL    XLL
Jersey Size
(circle one)
Youth:   L          Adult:  S    M    L    XL    XLL
Payment type
(circle one)
Cheque    Money order    VISA     Mastercard
Name of Cardholder _______________________  
  Card Number _______________________  
  Expiry Date mm/yy ______ / ______  
Total Amount
$ _________________
 
Signature
___________________________
Date
_______________
Waiver of responsibility – the applicant, their parents or guardians, agree that Leading Edge Hockey Development, and it’s instructors and directors are not liable for, nor will be held responsible for any accident or loss, however caused, and agrees to release Leading Edge Hockey Development from any claims and damages.
Parent's or Guardian's Signature ____________________________________

 

Leading Edge Hockey Development
Mail to:  555 Nimpkish Street, Comox, BC, Canada, V9M 3E4.


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