2017-2018
MEMBERSHIP FORM – St. Stephen Minor Hockey

 	PLAYER NAME & ADDRESS		Medicare/Health Ins # 		

			Birth Date: (Y/M/D)		
			Allergies:		

                         MOTHER / GUARDIAN	FATHER / GUARDIAN		
NAME 				
ADDRESS 1 				
ADDRESS 2 				
CITY 				
P CODE 				
HOME # 				
CELL # 				
WORK # 				
email 				

OPTIONAL EMERGENCY CONTACT NAME & ADDRESS)  	HOME #	CELL #	WORK #	

I, the undersigned certify the above information to be true and in consideration of the granting of this certificate to me with the privileges incident thereto, and by signing this certificate I have become subject to the rules, regulations and decisions of Hockey Canada, it’s Board of Directors, its Branches and/or divisions which may be restrictive in some areas such as movement from team to team, conduct etc. and I agree to abide by such rules, regulations and decisions of Hockey Canada, its Board of Directors, its Branches and/or divisions. Further, the information requested above is required by Hockey Canada to facilitate hockey programs on behalf of the registrant and Hockey Canada. Hockey Canada will treat this personal information with the utmost respect and in accordance with the Hockey Canada Privacy Policy at all times. Hockey Canada does not sell, trade or otherwise share the information we collect outside our Branches and Associations however we may from time to time use this information for the purposes of offering additional services, promotions, including promotions offered by third parties, and/or hockey specific research. This type of usage of your personal information by Hockey Canada, its Branches and/or associations is entirely at your discretion, should you choose to allow this type of usage please check the box here 
DATE	Parent/Guardian to PRINT Name
(Registrant may print name if age 19 or older)	Parent/Guardian Signature
(Registrant may print name if age 19 or older)	

**This section to be completed by team staff.

FEE DESCRIPTION 	AMOUNT		DATE PAID	TYPE (Cheque, etc.)	AMOUNT