City of New York, Parks & Recreation
Michael R. Bloomberg, Mayor
Veronica M. White, Commissioner

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Youth Street Hockey Registration

Participant Information

*First Name

*Last Name

Recreation Center Membership Number

*Address 1

Address 2

*Date of Birth

*Preferred Site

*Medical Condition

Yes No

Medical Condition Memo

Parent/Guardian Information

*First Name

*Last Name

*Address 1

Address 2

*Email

*Telephone 1

Telephone 2

Emergency Contact Information

*First Name

*Last Name

*Telephone