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Printout and fax back the enclosed authorization form. To print form click your print button at the top of your screen. Please print clearly.

Players name:_______________________________________________
Address_____________________________       City_______________         Prov/State ______  Country____________  Postal Code ___________ phone (      ) ________________________
email ________________________________________________________________________ 

Pre-Season Fee package register before Sept 1, 2000:
(  ) Basic $59.00 + $4.13 tax =     $63.13
(  ) Silver $135.00 + $9.45 tax = $144.45
(  ) Gold  $179.00 + $12.53 tax = $191.53
(  ) Platinum $275.00 + $19.25 tax = $294.25

I authorize my credit card (   )Visa or (  )Mastercard 
card #__________________________ expiry ______
to be run in the amount of $________________
cardholders name _______________________ signature  ___________________

I hereby agree/give my consent for myself/my child, (as parent and/or guardian) to have the information provided placed at hockeyregister.com at my/his/her own risk and peril. I have read and understand the terms and policy. I understand that  HockeyRegister.com  will not be held responsible for any  loss or damage however caused, and hereby agree to release and hold harmless HockeyRegister.com from all claims, damages, actions, loss, expenses and demands which may arise as a result of, or may have been contributed or occasioned by the action, inaction or negligence of HockeyRegister.com  if I am successful in any suit , action, or proceedings against HockeyRegister.com for any damages, loss, costs or expenses( including punitive damages) the award (including court costs) shall be limited to the amount of fees paid by me to HockeyRegister.com

X_____________________________________________________________________
signature of PARENT/GUARDIAN or player if 18 years or older

Please fax back form to HockeyRegister.com at 204-222-6018

 

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Last modified: Aug 22, 2000.

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