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Today's Date *

First Name *

Last Name *

Address *

City/Town *

State/County *

Zip/Post Code *

Father's Name *

Mother's Name *

Player's Phone *

Home Phone

Father's Cell *

Mother's Cell *

Emergency Phone

Email Address *

Date of Birth *

Height

Weight

Gender * Select Gender... Male Female

Present School Name

Present School Grade * Select Grade... 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Other

Hockey Experience Select Experience Level... None Less than 1 year 1-3 years 3-5 years 5+ years

Current Team(s), if any?

Position Played, if any?

Health Insurance Company *

Have you skated with Garry before? Select ... Yes No

If Yes, where did you last attend class (city and rink)

If Yes, when did you last attend (month/year)

How did you hear about us? Select... Brochure Friend Relative Coach Advertisement Facebook Youtube Surfing Online Other

Medical & Liability Release *

Concussion Form *