Players name:

Parent / Guardians Name(s):

Street Address:

City: Prov: Ontario

Postal Code: Phone:

Date of birth: Month Jan Feb March April May June July Aug Sept Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Do you have allergies / health problems? Yes No
If yes, please specify:

Emergency contact information (other then above):

Name:

Phone #:

Have you attended the Day Camp before? Yes No

How did you hear about our Day Camp? Oakville Beaver Abbey Oaks News Oakville Today Referral Internet Poster Flyer Community Guide

Print out your competed form and mail it to us with your payment to secure your spot!

Card Number:_______________________________________________________

Expiry Date:_________________________

Name as shown on card:______________________________________________

The undersigned is responsible for the conduct of the camper while participating in this program. It is understood that the undersigned person of legal age or legal guardian shall not hold the local league or the governing bodies, their instructors, administrators, officials or the facility used liable in the event of injury or loss. The camper listed above is registered under the care of the undersigned and assumes all risks through enrollment in this program with the understanding that although play is "non-contact", it consists of physical interaction capable of injury. Halton Roller Hockey DOES NOT issue refunds. I have read and I understand all items on this player's card.

Signature___________________________________________________________
Camper (if at least 18 years of age) or Parent/Guardian signature

Print out your competed form and mail it to us with your payment to secure your spot!

This is not a secure online form. You must print out this form and mail or fax it to our office to submit your registartion.