MIDGET Tryouts 2012-13 Season

YOU MUST PRINT THIS FORM

***NOTICE*** YOUR REGISTRATION WILL NOT BE COMPLETE UNTIL WE RECEIVE YOUR PAYMENT INFORMATION IF YOU PARTICIPATED IN THE TI SPRING PROGRAM, PLEASE BRING YOUR SPRING JERSEY TO ALL TRYOUTS.

Payment Information:

^{Player Name:       Birth Year 2003 2002 2001 2000 1999 1998 Midget Minor U16 Midget Major U18 Girls U12 Girls U14 Girls U16 Girls U19}

^{Contact Phone#:     Email Address:}   

^{Payment Method: Visa MasterCard Discover Check Cash        Amount Paid:}    (see below)

Credit Card Information: Card Number: Exp Date: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012 2013 2014 2015 2016 2017 2018 2019   3 Digit Code: Name on Credit Card:                       Address:             City, State, Zip:     Signature:  ______________________________________________________                              Note: a 3% Service Charge will be added for all Credit Card Transactions

YOU MUST PRINT THIS FORM! PAYMENT AMOUNT   (all payments are non-refundable) Midgets: $90 returning Fall 2011 players $130 pre-registration1 $150 Walk-in2 1 Mailed forms must be postmarked by Tuesday 7-3. 1 Faxes must be received by midnight on 7-6 2 If you do not mail or fax your form by the above deadlines with payment, you must bring the payment form to tryouts with payment for $150. Make your check made payable to: Team Illinois Hockey Club Complete and print this form and mail to: Team Illinois Registration PO Box 905 Elmhurst, IL  60126 or fax it to (630) 359-3734

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