Reg Form

Please take a moment to fill out our online form to helps us speed up the registration process. We will contact you within 5 business days to confirm the registration and a method of payment.

Please note, the items that are in black bold text are required for registration.

Thank you for your time.

Program Information

Start Date:

Program Name:

Personal Information

Parent/Guardian Name:

Participant Name:

Level of Ice hockey played in 2009/2010

Birthdate:

Health Card:

*No dashes or spaces

Contact Information

Address:

City:

Province:

Postal Code:

*No dashes or spaces

Home phone number:

*Require area code with no dashes or spaces

Work phone number:

*Require area code with no dashes or spaces

eMail address:

Method of Payment:

Interact

Cash

Cheque

Visa

MasterCard

If you are participating in any Ice hockey League,
please answer the folloing questions:

I would like to play:

Position played:

If you are a goalie, would you like to play goalie up one level or as a sub if needed on another team. There is no extra charge. yes no

If you (parent) are interested in coaching please check here

If you are interested in Sponsorship ($175.00), Please check here

Company Name:

Additional Information:

Release Of Liability/Acknowledgment of Risk

I give my approval to my child's participation in all activities of the Burlington Pond Hockey Training Centre and assume all risk and hazards incidental to such participation. I do waive, release, absolve, indemnify, and agree to hold harmless the Burlington Pond Hockey Training Centre and/or its proprietors. I certify that the applicant is in good physical and mental health and is able to participate in the physical activity of a vigorous program

I AGREE

I DISAGREE