2016-2017 HOCKEY REGISTRATION FORM
Player’s Name: ________________________Player’s Birthdate:_______USA Hockey#_______________
Have you done the IMPACT Concussion Test? Y/N If so, when was the last time you took it?__________
Player’s Age: _______Grade for 2016-2017:______Number of Regular Seasons w/ the Wildcats: _______
Number of Summer Seasons w/ the Wildcats: _________Number of years Playing Hockey: ___________
Preferred Position: ____________Travel Team (if any):________________________________________
School: _______________________________Player’s cell #:____________________________________
Parent’s Name: ________________________________________________________________________
Address: _____________________________________________________________________________
Parent’s email: __________________________________Parent’s Cell #:__________________________
Home phone #:___________________________
PLEASE SELECT WHICH PAYMENT TYPE
AMOUNT PAID: ___________ CASH: _____PAYPAL/CC:_______ CHECK: _______CHECK #: _________
PAYMENT RECEIVED: Y/N
PWHA BOARD MEMBER INITIALS: ____________