Leading Edge Hockey Development |
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Name |
______________________________ | |||
Address |
______________________________________________________________________________ | |||
City |
______________________________ | Postal Code |
__________________________ | |
Phone |
______________________________ | e-Mail |
__________________________ | |
Parents Name |
______________________________________________________________________________ | |||
Playing Experience (yrs)_____________________ |
Age (as of Dec 31/10) |
__________________________ | ||
| Jersey Size (circle one) | ||||
| Youth: M L Adult: S M L XL XLL |
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| Program Choices | ||||
1.) |
___________________________________________________ | cost + gst _________________ |
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2.) |
___________________________________________________ | cost + gst _________________ |
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3.) |
___________________________________________________ | cost + gst _________________ |
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4.) |
___________________________________________________ | cost + gst _________________ |
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Total _________________ |
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| Payment Type | ||||
| Cheque Money order VISA Mastercard | ||||
Cardholder Name __________________________________________________________________________ |
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| Card Number________________________________ | Expiry_____/_____ | Date __________________________ | ||
Total Amount |
$ _________________ | Signature |
______________________________ | |
Waiver of responsibility – the applicant, their parents or guardians, agree that Leading Edge Hockey Development, and its 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 |
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| Parent's or Guardian's Signature ___________________________________________________________________ | ||||
Leading Edge Hockey Development Mail to: 555 Nimpkish Street, Comox, BC, Canada, V9M 3E4. |
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