IHD-Registration

Impact Hockey Development - Registration Form

Please take the time to carefully fill out this form. The details here are needed to accurately place you in the appropriate program. You will receive a "confirmation email" after submitting the form.

Thank you,
Tim Preston, IHD
info@impact-hockey.com

Personal Contact Information

First Name

Last Name

Email

Street Address

City and Province

Postal Code

Home Phone

Cell Phone

Parent/Guardian

Medical Services Plan

Birth Date

Program Details

Last Level Played

Position Played

Program Choice

Program Type

Payment Details

Card Type

Card Number

Card Expiry Date

Referred by Whom?

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