Jr. Express Program Registration

Fields marked with * are required

PLAYER FULL NAME *

DATE OF BIRTH (mm/dd/yr) *

SHOOTS *

POSITION *

HEIGHT (ft & in) *

WEIGHT (lbs) *

CURRENT TEAM *

LAST YEAR'S TEAM *

ADDRESS *

CITY *

PROVINCE *

POSTAL CODE *

PLAYER EMAIL

PARENT EMAIL *

PARENT PHONE

ALLERGIES

WAIVER *

I consent to receiving email correspondence from the Coquitlam Express, Junior Express Program, and affiliated programs.