Fredericksburg Ice Park Hockey School Fall ‘08

Child’s Name:_________________________

 

Address: _____________________________

 

City: ________________________________

 

State: _____________  Zip: _____________

 

Home Phone: __________________________

 

Cell Phone: ___________________________

 

E-Mail: ______________________________

 

DOB: _____________ Age: ______________

 

Parent/Guardian Name: __________________

 

If child is not registered during open registration, classes will be pro-rated at $20 per class.  Open registration dates:

 

August 1st through September 5th

 

October 17th through October 31st

Payment Method (please circle)

$225 for 15 weeks

 

Cash        Check     Visa

 

Mastercard           American Express

 

Total Amount Due:   $____________

 

Signature:___________________________________