Name *

First Name

Last Name

Position *

What positions do you play?

Attack / Attacker

Defenseman / Defender

Midfielder

Long Stick Midfielder

Faceoff / Drawer

Goalie

Highest Level of Play *

Highest level of competition?

Men's Club

Women's Cub

College - Varsity

College - Club

High School - Varsity

High School - JV

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Clearances *

Pennsylvania State Mandates – Child Protective Services Laws Contracted vendors/contracted staff must be in compliance with the current Child Protective Services Laws of Pennsylvania. Employees in direct contact with children are required to undergo three specific certifications as mandated by the state of Pennsylvania. The following background check investigations that are required include Child Abuse Clearance, Criminal Background Check, & FBI Fingerprinting.

I understand the current Child Protective Services Laws of Pennsylvania and will provide clearances upon request.