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248-926-5656

Date

Information Form

Last Name

First Name

Birth Date

Address

City

State

Zip Code

Home Phone

Cell Phone

Email

Hockey Association

Team

Level of Play This Year

Last Year

Coach's Name

Coach's Phone #

Position (check one)

Center

Left Wing

Right Wing

Left Defense

Right Defense

Goal

Hockey Goal

Date for Goal

Participant Name

Parent/Guardian Name

detroit@puckmasters.com

248-926-5656

50950 Century Court
Wixom, MI 48393

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