Keystone Region Club License Application
2025-2026 Season
Club Type
*
Junior Boys
Junior Girls
Adults
Club Status
*
New
Existing
Club Name
*
Club Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Club Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Club Email
*
example@example.com
Club Website
Loyalty Offers?
Yes
No
Unsure
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Club Director Information
Club Director
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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Next
Optional Club Admins
Skip this section if you do NOT have Club Admins
Club Admin #1
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Club Admin #2
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Club Admin #3
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: