Registration - entry form, 2016-17 Midland, ON Regional, Central Region, 2016-2017, Can Reg (International Silver Stick)

 

Name of Team:                                                                                                                                                                     

 

Division: Novice:                                                               Bantam:                                                                                                        

              Atom:                                                                Midget:                                                                           

 

            Peewee:                                                                

 

              

Classification:    “A”                                                                    “BB”                                                                                

              

City or Town:                                                                                Population:                                                                     

 

Name of League:                                                                                                                                                                                 

 

Name of Convener:                                                                 Telephone# of Convener:                                                           

              

 

 

Name:                                                                                           Name:                                                                              

 

Address:              ___________________________________                     Address: ___________________________________

 

Town:                                       Postal Code:                                 Town:                                   Postal Code:                     

 

Telephone: (H)                                 (Cell)                                   Telephone: (H)                                 (Cell)                   

 

Fax:                                                                                               Fax:                                                                                 

 

E’mail address: _____________________________                          E’mail address: ______________________________

 

Primary Contact:  ____________________________                        Cell # of Primary Contact _________________

 

 

Home     Body:                                                                                              Visitor:  Body                                                  

               Trim:                                                                                                             Trim: