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MON VALLEY DEK HOCKEY REGISTRATION FORM |
CHILDS NAME: ______________________________________________________________
ADDRESS: ___________________________________________________________________
CITY: _____________________________ STATE: ________________ ZIP: _______________
AGE: ______________________ BIRTHDAY: _______________________ SEX: ___________
TELEPHONE: _________________________________ EMERGENCY: __________________________
| NEEDS: | __________Hockey Stick | __________Elbow Pads | __________Shin Pads |
| __________Goalie Pads | __________Gloves |
Health Statement:
| Are there any ailments or allergies we should be aware of? | _______YES | _______NO |
If yes, please explain:
______________________________________________________________________________
______________________________________________________________________________
In case of emergency, I hereby give permission
to Mon Valley Dek Hockey staff selected to secure proper
treatment for the
above named child on this form.
| Please contact my physician: | _______YES | _______NO |
Name of physician:_______________________________________ Telephone______________________
Please list the name and number of all persons
authorized to pick up your child from the Dek Hockey program:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
| __________________________________ | __________________________________ |
| Parent/Guardian Signature | Date |
Amount Paid: _________________ Receipt Number:__________________ Date:_________________
