College Prospect 2021 Extra Registration

Name*

First Last

Birth Date*

MM

DD

YYYY

Height*

Weight*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Player Email*

Parent Email*

Best Email to be contacted*

Player Email
Parent Email

Phone

What year did you graduate from High School?*

Which schools/universities are you interested in attending?*

Do you play ice hockey?*

Yes
No

Do you play roller hockey?*

Yes
No

If yes, what organization and what team did you play on this year?

If no, would you rate yourself as a beginner or intermediate player?

What tournaments do you participate in? (click all that apply)

NARCh
State Wars
TORHS/2Hot4Ice
TCS
Other (please write in comments)

Please check yes or no if you'd like to be contacted by the NCRHA as well as NCRHA Member Clubs and Coaches.

Yes, please contact me.
No, please do not contact me.

Comment - Please include any accomplishments here such as Team North America, NARCh High SCorer, etc.

Include any comments or questions regarding the clinic, camp, or program.

Liability Waiver*

Yes

I have read and agree to the liability waiver and terms and conditions.

Parent or Legal Guardian*

Jersey Size*

T-Shirt Size*

Short Size*

Program Fee*

Price: $899.00

Payment*

Pay by Check
Pay by Venmo - Peter-Dale-10

Please choose if you wish to pay by check or using Venmo. If you pay by check, note that your spot is not reserved until payment is received.
Payment should be mailed to: Peter J Dale LLC PO Box 674, Pewaukee, WI 53072