RMMHA PLACEMENT APPEAL
Parent's Name
*
First Name
Last Name
Athlete's Name
*
First Name
Last Name
Division
*
Please Select
U11
U13
U15
U18
Address
*
Street Address
Unit
City
Province
Postal Code
Email
*
ENSURE THERE ARE NO TYPOS!
Home Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Appeal
*
Fee
*
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PLACEMENT REVIEW FEE
Includes Stripe processing fees
$206.00 CAD
$
206.00
CAD
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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