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Address:______________________________________________________________________________ |
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Over the Past
Five (5) Years, list the Counties and States in which you
have resided including your present address:
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___________________________________________________________________________________________ |
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| Business Name and
Address:__________________________________________________________________ |
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Prior Hockey Associations/Clubs/Teams on which you have played/coached
(including County and State |
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where
located):______________________________________________________________________________ |
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I am supplying
this information to Troy – Albany Youth Hockey for the purpose of
screening pursuant to the policies of the New York Amateur Hockey
Association and USA Hockey. I hereby waive, release, absolve, indemnify,
and agree to hold harmless Troy – Albany Youth Hockey from any claim
arising out of such screening to me whether the result of negligence or
for any other cause. |
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