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VANDERHOOF MINOR HOCKEY

REFEREE REGISTRATION FORM

Sept 1 2010-April 1 2011

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Staff Information

Level: _________ Age Group Preference _____________________________________________________________________________________

Last Name:_____________________________________First Name___________________________________________Male _____Female______

Age_____ Note: Anyone aged 18 and over is required to have a criminal record check.

Required by BCAHA

Contact Phone _______________________________________________________________________________________________

Street Address _____________________________________________________________________________________________

Mailing Address _____________________________________________________________________________________________

_____________________________________________________________________________________________

Email Address (Receipts/Contact) ________________________________________________________________________________

Medical Information

B C Care Card_________________________________________Doctor__________________________________________________

Check any medical conditions/disabilities:

___Asthma ___Diabetes ___Glasses ___Contact Lenses ___Seizures ___Blackouts ___Headaches

List any allergies: ______________________________________________________________________________________________

List any regular medications: ____________________________________________________________________________________

Emergency Contact: ___________________________________________________________________________________________

Referee in Charge Spencer Siemens.

Telephone:250-567-2143

Cell: 250-570-2658