ICE LAND   LEARN TO PLAY HOCKEY   REQUEST

Please fill out the following Participant Information
LAST NAME  
FIRST NAME  
ADDRESS  
CITY  
STATE  
ZIP  
TELEPHONE  
 NIGHT PHONE #  
 EMAIL  

*****Birthday Child's Information*****
CHILDS NAME  
DATE OF BIRTH  (mm/dd/yy)
AGE  
Birthday Child T-Shirt Size

*****Dates Requested*****
1st. Choice Day   Month: Date:
2nd Choice Day   Month: Date:
Estimated Participants
(please include chaperones)