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Registration

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Please note: the following form does not use encryption to transmit your data. If you are uncomfortable with this, please print this form out, complete it, and either fax it to Tom Rose at (519) 623-9149 or bring it to your first ice session.

Student's Name:* Birth Date:*
Position Played: Level:*
Weakness: Strength:
Address:*  
City:* Postal Code:*
Telephone Number:* Alternate Number:
E-Mail:  
MEDICAL INFORMATION
Health Card Number:*Verison Code:
List any medical conditions which the power skating/hockey skills clinic should be made aware of:
Emergency Contact Name:* Phone Number:*
Family Doctor:* Phone Number:*
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