REGENCY RECREATIONAL HOCKEY LEAGUE - (Lancaster, PA)

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* First:

* LAST NAME:

* USA Hockey Registration Zip Code used:

* Email address:

Check if goalie

Goalies: indicate playing interest:

* Are you currently trained in First Aid/CPR/AED use?:

* Do you have any other advanced medical training?:

Describe additional medical training:

Please list any medical conditions, medications, or concerns should the need arise for medical aid::

* Emergency contact name:

* Emegency contact phone:

* Emergency contact relation:

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