PLAYER APPLICATION 2016-­‐2017 PLAYER NAME: ________________________________________________________
PLAYER PARENTS NAME: ______________________________________________
ADDRESS: ______________________________________________________________
CITY: ____________________________________________________________________
PROVINCE/STATE: _______________________________________________________
COUNTRY: _______________________________________________________________
POSTAL CODE/ZIP: _______________________________________________________
CELL NUMBER: __________________________________________________________
EMAIL ADDRESS: ________________________________________________________
Describe yourself as a hockey player. What special special skills and qualifications
you may have as a hockey player.
3949 DUNNING ROAD, NAVAN, ONTARIO, K4B 1J1 Name the last 5 teams that you played for:
1. ___________________________________________________________
2. ___________________________________________________________
3. ___________________________________________________________
4. ___________________________________________________________
5. ___________________________________________________________
PRINT NAME : ________________________________________________________
SIGNATURE: ___________________________________________________________
DATE: _________________________________________________________________ It is the policy of this organization to provide equal opportunities with regard to race, color, religion, national origin, gender, sexual preference, age or disability. Thank you for completing this application form and for your interest in being part of the Glengarry Highlanders Hockey Academy.
3949 DUNNING ROAD, NAVAN, ONTARIO, K4B 1J1 EMERGENCY CONTACT Name:
Date of Birth:
__________________________________
_________________________________
Parent’s Name:
Parent’s Name:
__________________________________
_________________________________
Address:
Address:
___________________________________
_________________________________
___________________________________
_________________________________
___________________________________
_________________________________
Home Phone
Work Phone
Home Phone
Work Phone
______________
_______________
_____________
_____________
Email Address:
Email Address:
______________________________________ ___________________________________ Primary Emergency Contact:
Secondary Emergency Contact:
__________________________________
_________________________________
Address:
Address:
___________________________________
_________________________________
___________________________________
_________________________________
___________________________________
_________________________________
Home Phone
Work Phone
Home Phone
Work Phone
______________
_______________
_______________
_____________
3949 DUNNING ROAD, NAVAN, ONTARIO, K4B 1J1 MEDICAL INFORMATION Medical/ Injury Details:
Detail any medical conditions/ allergies that we should be aware of?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Please provide details of medication that must be administered:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Do you have any past or current injuries that we should be aware of?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
If yes, please provide further details:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Any Other Information:_______________________________________________
____________________________________________________________________
____________________________________________________________________
Signed: ___________________________ Date: ___________________________
3949 DUNNING ROAD, NAVAN, ONTARIO, K4B 1J1 Can you please explain your short and long term hockey aspirations.
What is your expectation of our Hockey Program / Team.
3949 DUNNING ROAD, NAVAN, ONTARIO, K4B 1J1