| DAYTONA BEACH SPRING BREAKAWAY 2K4 ENTRY FORM |
| AGE
GROUP(Circle one) |
8<
10< 12< 14< 16< 18< Adult (18 >) |
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| Do you
require USA Hockey InLine Weekend Warrior Membership? |
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Yes |
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No |
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| Team City: |
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| Team Nickname: |
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| Home Jersey
Colours: |
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| Away Jersey
Colours: |
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| Contact Person: |
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| E-Mail Address: |
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| Street Address: |
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| City,State,Zip |
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| Telephone: Day- |
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Night- |
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| FAX : |
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| Mail this entry form to: FCIHI,
3850 Long Grove Lane, Port
Orange, FL 32129 |
| Please
enclose check/money order payable to: FCIHI Entry Fee: $375 |
| **Tournament
entry information package will be delivered upon receipt of deposit/payment |
| If you decide
to enter the tournament, please contact Jeff Ning at (386) 235 - 5208 before
mailing entry form. |
| PLEASE
COMPLETE ALL SECTIONS OF THE ROSTER FORM BELOW. |
| ROSTER
(Maximum of 15 including goalies) |
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Number |
Name |
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Position |
USAHI Member # |
DOB |
| 1 |
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| 2 |
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| 3 |
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| 4 |
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| 8 |
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| 9 |
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| 10 |
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| 11 |
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| 12 |
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| 13 |
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| 14 |
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| 15 |
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| COACH |
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| COACH |
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| COACH |
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| NOTES
(including Scheduling Requests): |
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