ONLINE REGISTRATION FORM

STUDENT (*Required Fields)

First Name*:
Last Name*:
Email*:
Age as of Jan 1/12:
Address Line 1:
Address Line 2:
City:
Province:
Postal Code:
Phone – Home:
Phone – Work:
Medical History:
Comments:
Enter Code*:

CAMP (Check one or more)

March Break March 12-16, 2012
Brampton (Summer) August 20-24, 2012
Don Cherry’s Lunch Option (Add $35)

PAYMENT

Applications must be accompanied by a minimum $100 deposit.

Cancellation Policy: In the event that it is necessary to cancel, a refund will be granted, subject to a $25 administration fee.

The applicant agrees that GAME CANADA HOCKEY SCHOOL and/or its proprietors will not be held responsible for any accidents or loss, however caused, and agrees to release the proprietors from all claims or damages which may arise by result of or by reason of such accidents or loss.

Credit Card Type: Securely Accepting Visa And Mastercard

Credit Card Number – – –
Expiry Date:

SIGNATURE OF CAREGIVER*:

PLEASE TYPE THE FULL NAME IN BOX ABOVE
THIS IS TO BE TAKEN AS EQUIVALENT TO A SIGNATURE.

*E–CONFIRMATION WILL BE SENT ON RECEIPT OF DEPOSIT.