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Applicant Name:
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Email:
Address:
City, State, Zip:
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Home phone:
Date of Birth:
How long has applicant been a member of
Melrose Youth Hockey?
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Parent/Guardian name:
Parent/Guardian phone:
Parent/Guardian address:
City, State, Zip:
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TEAM INFORMATION |
Player's current team (Mite, Squirt, Pee Wee,
etc.)
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Player's current level (A, B, C, D)
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Head Coach's name:
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REFERENCES
(OPTIONAL)
Please provide 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:
Reference 1
Reference 2
Reference 3
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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. Please be advised all information provided
will be held in strict confidence.
Additional Comments:
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