Leading Edge Hockey Development
2010 Registration Form

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
Program Choices
1.)
___________________________________________________
cost + gst _________________
2.)
___________________________________________________
cost + gst _________________
3.)
___________________________________________________
cost + gst _________________
4.)
___________________________________________________
cost + gst _________________
 
Total _________________
Payment Type
Cheque    Money order    VISA     Mastercard
Cardholder Name __________________________________________________________________________
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

Parent's or Guardian's Signature ___________________________________________________________________

Leading Edge Hockey Development

Mail to:  555 Nimpkish Street, Comox, BC, Canada, V9M 3E4.
FAX: 250-339-0790

 

 

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