REGISTRATION FORM FOR SIMPLOT WESTERN CANADIAN POND HOCKEY CHAMPIONSHIP

If you haven't been contacted by Brent to confirm registration, please call him at 204-856-3501 or 239-7024

$250.00 Per Team-payable As Soon as Possible 

February 20-22, 2009

 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 Brent Budz
1800 Saskatchewan Ave. West
Portage la Prairie, MB  R1N 0N9
*  Payment is required in full 

* A waiver form must be signed by all team members, when registration takes on the evening of Friday, February 13, 2009.
   
By submitting this form you and your team agree to the following:
All players are 18 years of age or older as of  Feb 20, 2008.  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.