2019 Directors Cup Prospects Program

REGIONAL PRE-REGISTRATION FORM

1st year – Male Bantam

Name:
Address:	Date of Birth:
City:	Province:	Manitoba	Code:
Telephone:	E-Mail:
2017 /18 Team:
Position:
Height:	Weight:	Shot:	L or R
In Case of Emergency:
Contact:	Relation:
Telephone:	Alternate Number:
Medical Number:	Personal Health Number:

Please fax or email the Pre-Registration Form to:

Region	Contact	Fax Number and E-mail
204-623-6250
Norman	Rene Gagnon 204-358-0492	Email – renegagnon96@gmail.com ron.larocque@ckpi.com

If you have any questions regarding the Male Bantam Directors Cup program, please contact your Regional Director or local contacts.

Thank you.