Adult Individual Registration

Fields marked with an * are required.

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Player Name

First Name

Last Name

Address

Street Address

City

Country

Phone

Player Birth Date

Player Email

If any allergies or health problems please describe below

Emergency Contact

Emergency Contact Name (Other than Parent / Guardian Above)

Emergency Contact Phone (Other than Parent / Guardian Above)

Player Experience & Info

Years of eperience

Additional Info

Payment & Waiver

Click here to read waiver (opens in a new window, make sure popup blockers are disabled)

Accept Waiver

I have fully read and fully understood the Halton Roller Hockey waiver form

Signature

By writing my name into the signature box, I understand that my child will be participating in roller hockey at Halton Roller Hockey, I understand all the risks attached to the sport in which my child will participate.

Full Name

Sign

Payment

Select

Payment

CouponApply

Discount

Subtotal

Tax

Total CAD