2012 SUMMER CAMP REGISTRATION

#1 Player's Name: *

First

Last

Age: *

Address:

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

Contact Number: *

###

####

Parent's Name: *

First

Last

Email: *

Camp Selection:
**$25 off total bill when registering for more than one program** *

Spring Shooting Clinic ($200.00)

Hockey/Golf Camp ($375.00)

Girls Camp ($425.00)

Super Elite Camp ($425.00)

Day Camp ($425.00)

Hockey/Lax Camp ($375.00)

High School Skills Clinic ($200.00)

Power Skating/Stick Handing Clinic ($200.00)

Advanced Goalie Camp ($425.00)

Goalie Camp ($425.00)

Jersey Size: *

Waiver: *

Yes

I, parent/guardian of the camper, hereby authorize the staff of the Leach Bros. Hockey LLC to act for me according to his/her best judgment regarding any emergency requiring medical attention for the camper. I will be responsible for the cost of medical attention and treatment. I hereby waive and release the Leach Bros Hockey LLC, its employees, agents, camp staff and facility from any and all liability for injuries and loss of property incurred while attending the camp. Parents must notify camp staff prior to commencement of any special health needs.

How will you be paying: (next screen with take you to payment option) *

By Check: payable to Leach Bros. Hockey

Paypal: andrew@leachbroshckey.com

Paypal: Credit-card (Please note: To pay by credit-card/debit, you must click on "Don't have a PayPal account?"

Referal Name: