Remember: Floor Hockey 2019 is played at the Y-Center's Multi-Sports Complex
PHONE (primary) (269) ___________________________ (secondary) (269) ___________________________
ADDRESS ___________________________________________ZIP CODE 490 ____
BIRTHDATE (month/day/year) __________________ CIRCLE: MALE FEMALE
CIRCLE YOUR PRESENT GRADE: PK* K 1 2 3 4 5 6 7 8
PK* means eligible for K in Sept. 2020
SCHOOL THAT YOU ATTEND ______________________________
PARENTS'/GUARDIANS' NAMES _________________________________________________(please print names)
Email address ___________________________________________
PLAYERS' CHECK LIST:
_________ Check here if interested in being a referee. Minimum 7th Grade.
_________ Enclosed is my payment of $55.00.
PARENTS' CHECK LIST:
_________ COACH (for my child's team)
_________ ASSISTANT (for my child's team)
_________ CONCESSION WORKER (one time only)
_________ MEDICAL PERSONNEL - Although rarely needed, it's nice to know that there's someone in the stands who might be able to help if an injury occurs. If you identify yourself and an emergency occurs, we may contact you. If you are trained for this category, please circle your profession: Doctor, Nurse, Police Officer, Firefighter, E.M.T., or list any other category.
Please print out and mail this form to:
If you have any questions, email Gary Lincoln at email@example.com or call 979-4336.
All checks/money orders should be made out to "WPMC".
Return to WPMC Floor Hockey Page.