Registration Form 2023-2024 (Elgin-Middlesex Canucks)

Print Registration Form 2023-2024

Date of Birth^*

mm/dd/yyyy

Father's Name
Mother's Name
Street Address
City^*
Postal Code
Home Phone^*

Example: ###-###-####
Cell Phone

Example: ###-###-####
Email Address^*

Example: yo[email protected]. Your submission will be sent to this address.
Work Phone

Example: ###-###-#### x###
Player Resident at Address Since^*

yyyy
Emergency Contact Name
Emergency Contact Phone

Example: ###-###-####
Doctor's Name
Doctor's Phone Number

Example: ###-###-####
Does Player have any Medical disabilities?
NoYes
If "Yes" to medical, explain
Has one parent completed the Respect in Sport Parent Program (mandatory for your player to attend tryouts). Proof will be required at tryouts before player attends.^*
Home Association^*
Respect in Sport Parent Program Number (if known)
Player's Position^*
Previous Team 2022-2023^*

Hockey Center Played In
Previous Team 2021-2022^*

Hockey Center Played In
I understand that by submitting the information in this form that I certify it to be true and that I have become subject to the Rules & Regulations, Constitution and Policy of EMHA. I agree to abide by such Rules & Regulations, Constitution and Policy.

I agree to the terms and conditions stated above^*

Human Validation