KITCHENER WATERLOO PREDATORS VBC
SPIKES PROGRAM

Name: Address:

City: Home Phone #:

Postal Code: Birthdate:

MONTH January February March April May June July August Setpember October November December DAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YEAR 1995 1996 1997

Mother or Father's Name: Parent's E-mail Address:

Emergency Contact: (other than parent) Emergency Contact Phone #:

PLEASE MAIL A CHEQUE FOR $80.00 TO Kitchener Waterloo Predators Spikes Program 337 Beechlawn Drive Waterloo, ON N2L 5L8 Make Cheque Payable to "Kitchener Waterloo Predators Spikes Program"

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