UNDER CONSTRUCTION

PORT HURON MINOR

HOCKEY ASSOCIATION

REGISTRATION

PLAYER INFORMATION

NAME:

BIRTHDATE: (MM/DD/YY OR MM/DD/YYYY)

DIVISION: SELECT ONE LEARN TO SKATE (1 SESSION) LEARN TO SKATE (BOTH SESSIONS) MINI MIGHT MIGHTY MITE MITE HOUSE MITE TRAVEL SQUIRT HOUSE SQUIRT TRAVEL PEEWEE HOUSE PEEWEE TRAVEL BANTAM HOUSE BANTAM TRAVEL MIDGET HOUSE MIDGET TRAVEL  

HEALTH INSURANCE COMPANY:

HEALTH INSURANCE POLICY NUMBER:

PARENT INFORMATION

NAME:

ADDRESS:

CITY:

STATE:

HOME PHONE: CELL PHONE:

EMAIL:

PAYMENT INFORMATION

CREDIT CARD: MASTERCARD VISA SELECT ONE

CARD NUMBER:

EXPIRATION:

NAME ON CARD:

MULTIPLE PLAYER DISCOUNT YES NO

ENTER AMOUNT TO PAY:

IF INFORMATION IS CORRECT PRESS THE SUBMIT BUTTON