Individual Registration

Please enter information in the form below to process registration for event Parkland Rangers Team Tryout & Try-Out Conditioning Ice Sessions.

Player First Name *

Player Last Name *

Player Email *

Player Cell Phone Number *

Date of Birth *

Parent 1 Name *

Parent 1 Phone Number *

Parent 1 Email *

Parent 2 Name

Parent 2 Phone Number

Parent 2 Email

Address *

City *

Postal Code *

Province *

Player Height *

9 Digit Manitoba Health Card Number *

Previous Team *

Previous Coach *

Preferred Position *

Preferred Position (Second Choice) *

Does Player have any personal health information we should be aware of? (allergies/injuries) *

Yes

Health Information Explanation *

Additional Comments

Amount

Payment Method

Credit Card Payment

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Holder Name*

Credit or debit card*