Belleville Minor Hockey Association (BMHA)

Time Keeper's Clinic Registration Form
(This is a FREE clinic)

• Please complete all of the following sections, fields marked with a * are required .
• Upon completion of the online clinic registration form, a registration receipt will be sent via email to the email address provided.

Registrant's Name, Address and Contact Information:

*	First Name:
*	Last Name:
*	Address:
	Address 2:
*	City:
*	Province:
*	Postal Code:
*	Email Address:
*	Phone:
*	Enter the code displayed: