Belleville Minor Hockey Association (BMHA)

Defense Clinic Registration Form
($25.00 Fee for replacement receipts)

• Registration deadline is January 9, 2012, registrations received after January 9, 2012 will be placed on a waiting list and contacted should a space open up.
• Registration is not considered complete until full payment has been received by the BMHA.  The BMHA no longer accepts personal cheques, you may register online using a Visa / Mastercard or in person at the BMHA Office using Cash, Interac, Visa or Mastercard.
• The BMHA has an established Code of Conduct for Players, Clinic Instructors, and Parents as published in the BMHA Rules and Regulations booklet. As the parent / guardian of the registered player, you agree to abide by these policies.
• By completing the clinic registration form, I am indicating that I have read and understand the above.

Completing the Online Registration Form:

• Please complete all of the following sections, fields marked with a * are required .
• Upon completion of the online clinic registration form, you will be prompted with a payment page.  Please follow instructions on the screens provided.  A payment and registration receipt will be sent via email to the email address provided.
• With the exception of the E-Mail address, all fields (unless otherwise indicated) refer to the player. Please enter Parent/Guardian information in the fields provided.

Player Name, Address and Contact Information
(Enter Parent/Guardian E-Mail address in e-mail address field):

*	First Name:
*	Last Name:
*	Address:
	Address 2:
*	City:
*	Province:
*	Postal Code:
*	Email Address:
*	Phone:
*	Players Date of Birth (YYYY-MM-DD)
* Players Gender Male Female
*	Parent/Guardian (1)
	Parent/Guardian (1) Alternate Phone Number
	Parent/Guardian (2)
	Parent/Guardian (2) - Alternate Phone Number
	Are there any medical conditions the BMHA should be aware of?
* Player's position of play: Forward Defence Goaltender
*	Plays on the following team:
*	Defense Clinic Registration Fee	$30.00 Quantity
	Comments or Questions
	Total:
*	Enter the code displayed: