COLE HARBOUR PLACE
SUMMER 5 ON 5 HOCKEY LEAGUE 2015
Please complete this form and bring or fax with payment to:
Cole Harbour Place, 51 Forest Hills Parkway, Dartmouth, Nova Scotia
FAX: (902) 464-5124
Use 1 form per child and Please Print Clearly
Confirmed registrations are NON REFUNDABLE except for cancellations due to lack of
registration or medical emergencies (with doctor’s note)
Cheques are made payable to Cole Harbour Place. All NSF cheques will be charged
$30.00. Deadline for payment by cheque is June 12, 2015.
If registering by FAX, payment can only be made by a credit card.
Full payment must accompany your form
10 week program June 28 - August 31
Coached by Dalhousie University Players
PARTICIPANT INFORMATION
Last Name
First Name
Birth Date (dd/mm/yyyy)
/
Middle Name
Position
/
Medical Conditions that we should be aware of? (please describe)
Mailing Address
City / Town
Phone
(
Postal Code
Email
)
Players participate at the age group they are going into for 2015/16 hockey season. There is no checking.
Atom (2005, 2006)
Peewee (2004, 2003)
Bantam (2002, 2001)
Midget (1998, 1999, 2000)
PARENT / GUARDIAN INFORMATION
Name
Phone
(
)
Email
PAYMENT INFORMATION
Costs
$150.00
Signature
Credit Card Number
Expiry
/
/
Date