ALBERNI VALLEY MINOR HOCKEY ASSOCIATION

P.O. Box 241, Port Alberni, BC V9Y 7M7

 

www.avmha.com    Phone/Fax (250) 724-6844

 

PLAYER INFORMATION:

Last Name

First Name

Birthdate  dd/mm/yyyy

Division

 

Street Address

City

Postal Code

 

Sex (M or F)

Care Card #

Doctor

Dr. Telephone #

 

 

PARENT OR LEGAL GUARDIAN INFORMATION – MUST RESIDE AT PLAYERS ADDRESS

Last Name

First Name

ADDRESS SAME AS PLAYER

 

Home Phone #

Work Phone #

Relationship

Mother              Father             Other

Cell Phone#

Fax #

Email

 

 

PARENT OR LEGAL GUARDIAN INFORMATION

Last Name

First Name

Address (if different from player)

 

Home Phone #

Work Phone #

Relationship

 

Mother             Father              Other

 

ADDITION EMERGENCY CONTACT:

Last Name

First Name

Telephone #

Relationship

 

 

 

MEDICAL INFORMATION:         Please indicate Yes or No

Asthma

 

Diabetes

Epilepsy

Wears Glasses

Wears Contact Lenses

 

Recurring Headache

Seizure

Blackout

Chest Pains

 

 

 

 

 

Please indicate any medications taken regularly, allergies, or other conditions:

 

 

 

  

 

WAIVER:  We hereby acknowledge the authority of the CHA, BCAHA, PCAHA and the minor Hockey Association, and agree to carry

out and abide by the Constitution, Bylaws, Rules and Regulations of those associations.

 

EQUIPMENT:  We, at the end of the season covered by this registration, agree to return all equipment provided by the Minor Hockey

Association in good condition and should we fail to do so we agree to reimburse the Association for the replacement cost of the same.

 

RELEASE:  In consideration of this application to play under the auspices of the Minor Hockey Association, I do hereby for myself, heirs,

executors, administrators and assigns, remise release and forever discharge the CHA, BCAHA, PCAHA, the Association, its officers or

anyone acting on their behalf from all manner litigation, damage claims, or demands in law or equity which I may have or acquire by reason

of person injury to the player, loss or damage to property, which may occur during or by reason of participation in the activities of the Association.

 

 

SIGNATURE OF PARENT OR GUARDIAN:__________________________________________________DATE:_______________________

 

 

 

 

 

ALBERNI VALLEY MINOR HOCKEY ASSOCIATION – PLAYER REGISTRATION 2008-2009 SEASON

 

NAME

BIRTH YEAR

DIVISION

 

 

 

 

 


 

REGISTRATION FEES

 

 

 

Base Registration

Mites (6 & under) Novice (7 & 8)

$260.00

 

 

 

$

Atom (9 & 10)

Pee Wee (11 & 12)  /  Bantam (13 & 14)

Midget  (15, 16 & 17)

 

$375.00

Juvenile (18 +)  

$300.00

Rep Team Tryout Fee

Non-refundable, one ice session guarantee. 

 $20.00

 

 

$

Late Registration Fee

Only Registrations Submitted After March 31, 2008

  $100.00

 

$

 

Total Payable

 

 Date Paid in Full

Method of Payment

   Cash     Cheque     Visa 

   Mastercard 

 

$

OR 

Amount Paid May 20th2008

Method of Payment

   Cash     Cheque     Visa     Mastercard 

 

$

Amount Paid June 20th 2008

Method of Payment

   Cash     Cheque     Visa     Mastercard 

 

$

Amount Paid July 20th, 2008

Method of Payment

   Cash     Cheque     Visa     Mastercard 

 

$

   Jersey deposit attached (Post-dated cheque for $75.00 dated March 31, 2009 made payable to AVMHA. 

(Competitive (Rep) Team Players will be required to submit an additional $75.00 post-dated cheque to Rep Team after season starts)

   Player requests to play female hockey only

Are you interested in coaching this year? Please circle                YES                 NO

 

Credit Card Information

   Visa     Mastercard 

Name on Card: (please print)

Card #:

Expiry Date: