Coach Clinic Reimbursement (Whitby Minor Hockey)

Coach Clinic Reimbursement

PLEASE NOTE THIS FORM IS FOR HL ONLY. IF YOU ARE PART OF REP BENCH PLEASE SUBMIT THROUGH THE REP BUDGET.

Please ensure all contact information is current. This information will be used to mail reimbursement cheques. ALL CHEQUES WILL BE ISSUED IN JANUARY.

First Name^*

Required

Last Name^*

Required

Street Address^*

Required

City^*

Required

Postal Code^*

Required

Primary Contact Telephone Number^*

Required

###-###-####

Email Address ^*

Required

I am currently a member and/or support staff of the following team:

Division ^*

Required

Example: U5,U6, U7

Team Number^*

Required

Date of Completion ^*

Required

Cost^*

Required

Method of Payment ^*

Cash
Cheque
Credit Card

Required

Please attach a copy of your paid receipt for an OMHA clinic^*

Allowed extensions: .jpeg, .jpg, .png, gif, .pdf, .doc, .docx, .xls, .xlsx, .ppt, .pptx.
Maximum # Files: 1. Maximum File Size: 4MB.

Your application will NOT be considered without this information attached.