College Prospect Registration - Farm Tough Hockey

Name*

First Last

Birth Date*

MM

DD

YYYY

Height*

Weight*

Email*

Phone

Address

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

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)

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: $849.00

Payment*

Pay by Check
Pay by Credit Card

Please choose if you wish to pay by check or credit card. 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

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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