GSS - Registration Form 2010

T-Shirt Size: Youth S M L XL Adult S M L XL (please circle one)

Skater's Name:

Date of Birth:

NEW - Prices include ALL taxes

Week 1: July 5th - July 9th, 9:00 - 4:00

$285.00

Address

Week 2: July 12th - July 16th, 9:00 - 4:00 pm

$285.00

Week 3: July 19th - July 23rd, 9:00 - 4:00 pm

$285.00

Postal Code

Week 4: July 26th - July 30th, 9:00 - 4:00 pm

$285.00

Method of Payment

Week 5: August 3rd - August 6th, 9:00 - 4:00 pm (no skating Aug 2nd)

$245.00

Cheque payable to Georgina Summer Skate

Email Address

Week 6: August 9th - August 13th, 9:00 - 4:00 pm

$285.00

Cash

Visa - To be processed by Skater's Edge in Newmarket

Phone #

SPECIAL RATE: Full 6 Week Program, $1500.00

MasterCard - to be processed by Skater's Edge in Newmarket

American Express - to be processed by Skater's Edge in Newmarket

PAIRS / OPEN ICE - 6 weeks, Monday - Friday 8:00 - 9:30 am: $400.00

OR $75.00 per week, OR $20.00 per day

Total:

Credit Card #

Expiry Date

Signature

Information

Skate Canada #

Emergency Contact Information

Emergency contact Name:

The applicant and parent/guardian agrees that the Georgina Summer Skate and it’s proprietor will not be held responsible for any accident, loss or injury, however caused, and to release the proprietors from all claims or damages, which may arise as a result of such accident, loss or injury. In case of emergency, I hereby give permission to seek out medical treatment my child may require. I agree to inform the director if I choose not to allow any pictures of my skater to be used for publicity purposes on brochures or the website.I also agree to the terms of the application.

Relation to skater:

Emergency contact phone: (home)

(work)

Please list any food allergies or special concerns (if applicable):

Signature (parent or guardian if applicant is under the age of 19)

Private Coach Info:

If your coach is not currently on staff with us, please provide us with their name and

address. We will send them a copy of your schedule and a confirmation of the weeks you

Space is limited. To avoid disapointment, please ensure your form is in early.

are skating.

Coach's Name:

Please return all registrations to: 224 Wynhurst Rd., Keswick, ON, L4P 2R5