^{Nike Bauer Select Region:       Western      Mid West    Eastern}     

^{Last Name:     First Name:    MI:}  

^{Address:      
 
City:               State/Prov:       Zip:}   

^Country:  USA Canada Other      ^Citizen:  USA Canada Other

^{Date of Birth:}    (enter with slashes   mm/dd/yyyy)

^{Home Phone:           Parent Cell#:}             

^{Parent/Guardian    First Name:    Last Name:}   

^{E-Mail Address:      
 
E-Mail Address:}      

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^{Primary Position: Forward      Defense   Goaltender                         Shot / Catch:   Right      Left}

^{School Grade:     School GPA:     ACT:     SAT:}  

^{Current Team:         Current Coach:}         

^{Coaches Phone:     Coaches E-Mail Address:}     

 ^{Other Hockey References:}       

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^{I am available to attend the "Nike Bauer Residential Camp" in Chicago June 21-25, 2009?    YES    NO}

^{If selected, I am available to attend the "World Class Challenge" in Moscow, Russia August 5-13, 2009?    YES    NO}

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^{Strength as a Hockey Player:}

^{Who is the best player you played this season and which team does he play for:
Player:         Team:}       

^{Preferred Jersey Number (please pick three):}                                 

^{Jersey Size:   Youth Small     Youth Medium    Youth Large
                Adult Small     Adult Medium    Adult Large      Adult X-Large     Adult 2X-Large}