REGISTRATION FORM FOR E.F. MOON CONSTRUCTION WESTERN CANADIAN POND HOCKEY CHAMPIONSHIP

If you haven't been contacted by Jeff to confirm registration, please call him at 204 857 7882.

$300.00 Per Team-payable As Soon as Possible 
Early Registration: $250 if paid in full before January 30, 2012

February 24-26, 2012

 Team  Name:
 * Team Captain's Name:
* Team Captain's Email Address
 * Team Captain's Mailing Address:
 * Team Captain's City/Town:
* Province:
* Team Captain's Phone Number
Player 2 Name:
Player 3 Name:
  Player 4 Name:
  Alternative Player Name:
 *  Payment  

* Mandatory

Roster can be accepted up to 5 days in advance of the event

Make cheques payable to Western Canadian Pond Hockey Championship

Send cheques to:

Attention Jeff Dubois
28 Meighen Avenue
Portage la Prairie, MB. R1N 3G4
*  Payment is required in full 

* A waiver form must be signed by all team members, when registration takes on the evening of Friday, February 24, 2012.
   
By submitting this form you and your team agree to the following:
All players are 18 years of age or older as of  Feb 24, 2012.  Players must show proof of age upon registration and can only play for one team.  Any teams with ineligible players will forfeit their place in the Championships
The names and likenesses of my team and its members to be used for tournament promotion via the official website , public relation campaign and media campaign.