Belleville Minor Hockey Association (BMHA)

2012 Screamin Eagles Summer Hockey Registration Form
($25.00 Fee for replacement receipts)

• Registration deadline is June 4, 2012, registrations received after June 4, 2012 will be placed on a waiting list and assigned to a team (space permitting).
• Registration is not considered complete until full payment has been received by the BMHA.  The BMHA no longer accepts personal cheques, you may register online using a Visa / Mastercard or in person at the BMHA Office using Cash, Interac, Visa or Mastercard.
• In an effort to provide fair competition through balanced teams, some players may be transferred between teams at the begining of the season
• The BMHA has an established Code of Conduct for Players, Coaches and Parents as published in the BMHA Rules and Regulations booklet. As the parent / guardian of the registered player, you agree to abide by these policies.
• By completing the player registration form, I am indicating that I have read and understand the above.

Completing the Online Registration Form:

• Please complete all of the following sections, fields marked with a * are required .
• Upon completion of the online player registration form, you will be prompted with a payment page.  Please follow instructions on the screens provided.  A payment and registration receipt will be sent via email to the email address provided.
• With the exception of the E-Mail address, all fields (unless otherwise indicated) refer to the player. Please enter Parent/Guardian information in the fields provided.

Player Name, Address and Contact Information
(Enter Parent/Guardian E-Mail address in e-mail address field):

*	First Name:
*	Last Name:
*	Address:
	Address 2:
*	City:
*	Province:
*	Postal Code:
*	Email Address:
*	Phone:
*	Players Date of Birth (YYYY-MM-DD)
* Players Gender Male Female
*	Parent/Guardian (1)
*	Parent/Guardian (1) Alternate Phone Number
	Parent/Guardian (2)
	Parent/Guardian (2) - Alternate Phone Number
	Are there any medical conditions the BMHA should be aware of?
* Players preferred position is: Forward Defence Goaltender
	I would like to volunteer as a:	Coach Trainer Convenor
	If volunteering, please provide your Speak Out (PRS) Certification Number
* Are you interested in sponsoring a team ($150.00 / team)? Yes No
*	Summer Hockey Registration Fee	$150.00
	Total:
*	Enter the code displayed: