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Please print this
form, completely fill it in, and or
deliver or mail it to
Jennifer Blanchard, Hockey Coordinator, Charlottesville Ice
Park, 230 West Main Street, Charlottesville, VA 22902.
REMEMBER: All lower and middle house
players must be currently registered with USA Hockey! Thank
you!
CHARLOTTESVILLE
ICE PARK
WINTER
2007 YOUTH HOCKEY LEAGUE REGISTRATION FORM
_____ Fall Rookie
League $200
_____ Fall Lower
House $240
_____ Fall Middle
House $240
_____
Goaltender $40
_______Equip. Rental $50
_____Position (Forward, Defense, Goalie)
Player's Name
__________________________________ Date of Birth
___/___/______
Address
_______________________________________ Phone
(H)________________
City/State/Zip
___________________________________
(W)________________
E-mail Address
_________________________________________________________
Name of Parent
Registering Child __________________________________
Address (if
different)_______________________________ Phone
(H)____________
City/State/Zip
___________________________________
(W)________________
E-mail Address
_________________________________________________________
Total Amount
Due $__________
Payment
___Check ____Credit Card (MC. Amex, Visa, Discover)
___Cash (In Person Only)
Credit Card #
_________________________________________ Expiry
Date_________
Name on Card
_______________________________________ Amount
$___________
I authorize
the Charlottesville Ice Park to charge my credit card for
the amount shown above:
__________________________________________________________
(Signature of
Cardholder Required)
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