CLINIC REGISTRATION

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PARENTS NAME

EMAIL

STREET ADDRESS

CITY

PROVINCE

POSTAL CODE

CONTACT NUMBER

PLAYERS NAME

AGE

CURRENT HOCKEY ASSOCIATION

MALE / FEMALE

DATE OF BIRTH

CURRENT DIVISION

WHAT LEVEL DO YOU PLAY

LOCAL LEAGUE

AE

REP

A

AA

AAA

WHAT CLINIC ARE YOU REGISTERING FOR

EDGES / AGILITY

POWER SKATING

DEFENSE

GOALIE

BODY CHECKING

U16-18 REP/A/AA/AAA/JR

PASSING /SHOOTING

PRE-SEASON PREP

HOW DID YOU LEARN ABOUT OUR CLINICS?

COMMENTS OR CONCERNS

PAYMENT AND REGISTRATION MUST BE COMPLETED BEFORE YOUR SPOT IS CONFIRMED, PAYMENT VIA E-TRANSFER TO breakawayperformancehockey@gmail.com

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