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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