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2019-20 BROCKVILLE BLAZERS REGISTRATION
PRE-REGISTRATION FOR OUR HOUSE LEAGUE.
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Email
*
Your email
The following form is for Registration purposes only. Payment for teams will be collected by team manager and coach.
Which Age Group will your child be registering for?
*
House League Grades 6-8
House League WAITING LIST Grades 3-5
Other:
What size reversible jersey will your child require?
*
youth medium
youth large
youth extra large
adult small
adult medium
adult large
adult extra large
adult xxl
Other:
Player Name (First, Middle, Last)
*
Your answer
Player Date of Birth
*
MM
/
DD
/
YYYY
Player Home Mailing Address (#, Street, City, Postal Code)
*
Your answer
Parent Name
*
Your answer
Parent Email for use during season.
*
Your answer
Parent Contact Number
*
Your answer
Alternative Contact Information (Emergency)
*
Your answer
Player's Club Last Season (Transfer from outside organizations to be approved)
*
Brockville Blazers
Brockville House League
Other:
Allergies, Medication or Medical Conditions
*
Your answer
Has your child had previous diagnosed concussions?
*
Yes
No
Unsure
Other:
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