REGISTRATION

PLAYER INFORMATION
Players Name (*)
Address (*)
City (*)
Postal Code
E-mail (*)
Primary Phone (*)
Business Phone
Parent/Guardian (*)
Name of program
Example "P.A. Day Camp":
Level (*)
Birth Year (*)
Gender (*)
Current Team (*)
CREDIT CARD INFORMATION
Name on Card
Credit Card Number
Card Type

Expiration Date Expiry Month


Expiry Year


digits on back of card
Verification Code
Payment Amount
SECURITY CODE (*)

Waiver Agreement (*)
The applicant agrees that GOLDEN GLIDE HOCKEY, its proprietors, participants and employees, will not be responsible for any accident or loss however caused, and agrees to release them from all claims and damages which may arise as a result of such accidents or loss. In the event that the applicant is incapacitated, or if the applicant is a child, I herby give you permission to seek out any necessary medical assistance required. In signing the application, the applicant acknowledges that he/she has read and understands the conditions and certifies that he/she is in good physical and mental health. All credit card transactions are subject to a 2% fee starting september 1st, 2014.