REGISTRATION FOR FARM TOUGH HOCKEY Camps, Clinics, and Programs Registration for Winter Camps Winter Rookies CampWinter Main Camp for SkatersWinter Main Camp for GoaliesUSM Camp - SkatersUSM Camp - GoaliesBeaver Dam Camp SkatersBeaver Dam Camp Goalies Winter Rookies Camp 2017 Tuesday December 26th 12 - 2pm at the Farm Cost: $69 Name* First Last Birth Date* MM DD YYYY Email* PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CommentInclude any comments or questions regarding the clinic, camp, or program.Parent or Legal Guardian*Liability Waiver* Yes I have read and agree to the liability waiver and terms and conditions.Program Registration Fee* Price: $69.00 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 53072Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Winter Main Camp - Skaters - 2017 Wednesday December 27th 9-11am, On Ice at Eble Thursday December 28th 9am - 12pm, Off Ice at The Farm Cost: $179 Name* First Last Birth Date* MM DD YYYY Email* PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CommentInclude 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*Program Registration Fee Price: $179.00 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 53072Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Winter Main Camp - Goalies - 2017 Wednesday December 27th, 2017 9-11am, On Ice at Eble Thursday December 28th 9am - 12pm, Off Ice at The Farm Cost: $179 Name* First Last Birth Date* MM DD YYYY Email* PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CommentInclude 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*Program Registration Fee* Price: $179.00 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 53072Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Winter USM Ice Concepts Camp - Skaters - 2017 December 27 & 28th 3-5pm at USM Cost: $169 Name* First Last Birth Date* MM DD YYYY Email* PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CommentInclude 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*Program Registration Fee Price: $169.00 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 53072Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Winter USM Ice Concepts Camp - Goalies - 2017 December 27 & 28th 3-5pm at USM Cost: $169 Name* First Last Birth Date* MM DD YYYY Email* PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CommentInclude 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*Program Registration Fee* Price: $169.00 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 53072Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Winter Beaver Dam Camp - Skaters - 2017 December 29th, 2017 for Squirts - Bantams On Ice Camp at Beaver Dam 12 - 2pm Cost: $59 Name* First Last Birth Date* MM DD YYYY Email* PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CommentInclude 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*Program Registration Fee Price: $59.00 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 53072Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Winter Beaver Dam Camp - Goalies - 2017 December 29th, 2017 For Squirts - Bantams On Ice Camp at Beaver Dam 12 - 2pm Cost: $59 Name* First Last Birth Date* MM DD YYYY Email* PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CommentInclude 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*Program Registration Fee* Price: $59.00 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 53072Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name
