Prospects Camp Registration

Run and Operated by the Nanaimo Buccaneers Junior Hockey Club

    Player Info:

    First Name:

    Last Name:

    Address:

    Phone Number:

    Email:

    Birthdate:

    Height:

    Weight:

    Position:

    Right or Left Shot?
    RightLeft

    Last Level Played:

    Last Team:

    Special Requests:

    Emergency Contact / Parent Info

    Parent 1
    Name:

    Phone Number:

    Email:

    Parent 2
    Name:

    Phone Number:

    Email:

    Medical Information

    Care Card Number:

    Allergies:

    Previous Medical Issues:

    Previous Concussions:
    YesNo

    If Yes, how many and how long ago:

    I confirm that both the player and parent have read and acknowledge both the league rules and the waiver form.

    Payment Information

    Please select one:
    Arrange cash payment with Carl OllechE transfer the funds to buccaneers@nullshaw.ca (Please reference players name)Credit Card (We will follow up with you via email to arrange payment)

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