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PLAYER INFORMATION
* First Name:
* Last Name:
* Street:
* City:
* Province:
* Postal Code:
* Home Phone:
* Email:
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PERSON MAKING THE PAYMENT
* Firstname:
* Lastname:
* Email:
* Home Phone:
* Cell Phone:


Signature: ___________________________________   Date: ____________________

Signature: ___________________________________   Date: ____________________

* required


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