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BURKE FUND - Print Form |
John & Thomas E. Burke Memorial Fund
Application for Disbursement - Melrose Youth Hockey 2006-2007 Season
| APPLICANT/PLAYER NAME | |||
| NAME | HOME PHONE | ||
| STREET | CITY, STATE AND ZIP | ||
| DATE OF BIRTH | HOW LONG HAS APPLICANT BEEN A MEMBER OF MYH? | ||
| PARENT/GUARDIAN NAME | ADDRESS (Street, City, State, Zip) | HOME PHONE |
| TEAM INFORMATION | |
| PLAYER’S CURRENT TEAM (Ex. Mite, Squirt, Pee Wee, Bantam) | PLAYER’S CURRENT LEVEL (Ex. A, B, C1, C2) |
| HEAD COACH’S NAME | |
| REFERENCES | OPTIONAL: Please provide three (3) references below. The provision of references is strictly optional. Opting to skip this section will not negatively impact or compromise consideration of the disbursement request. | ||
| NAME | CONTACT INFORMATION | RELATIONSHIP TO PLAYER/FAMILY | |
| 1. | |||
| 2. | |||
| 3. | |||
| Please provide a short narrative in the space below detailing the reasons why a request for assistance from the Burke Fund should be considered. Please write legibly. Attach a separate sheet if needed. Please be advised all information provided will be held in strict confidence. |
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| ADDITIONAL COMMENTS |
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| Signature |
| Date |
Completed applications can be submitted using any one of the following methods:
By U.S. Mail to the following address:
Melrose Youth Hockey - Burke Fund
c/o Frank Sorrenti
76 Wentworth Rd.
Melrose, MA 02176
or
Hand delivered to one of the following individuals: Frank Sorrenti, David Mahoney, or Jody Karelas.
