USA Hockey Registration #:

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First Name: Last Name:

Address:

City: State: AL AK AZ AR CA CO CT DE FL HI ID IL IA KS KY LA ME MD MA MI MN MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code:

Country of Citizenship:

Phone: Fax: Email:

Height: Weight: Date of Birth:

Father's Name: Occupation:

Mother's Name: Occupation:

Do you have any pre-existing medical conditions? No Yes

If yes, please explain:

ATHLETIC INFORMATION:

Current Team: League:

Position: Select Right Wing Left Wing Center Defense Goalie Shoot: Select Right Left

Coach's Name: Coach's Phone Number:

Team You Played for Last Year:

Team: GP G (GAA) A(Save%) PIM (W/L)

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