151 Chapel Street, Ottawa, Ontario, K1N 7Y2             Phone: 613-761-9620

info@springaction.ca

www.springaction.ca

Registration Form

March Break Camp 2013

Name: ________________________________________________________________________________

 

 

Address: ______________________________________________________________________________

 

 

City: _____________________________________     Postal Code: ______________________________

 

 

Phone: ____________________________________     Birth date (D/M/Y): ______________________

 

 

E-mail Address: ________________________________________________________________________

 

 

Emergency Contact Name: _____________________________________________________________

 

 

Emergency Contact Phone: (H) _______________________    (W)____________________________

 

 

How did you hear about Spring Action? _________________________________________________

 

 

 

 

Please Check the days you will be attending, and indicate whether extra care is needed:

**Extra Care is available from 8am-9am and 4-5pm at a cost of $5.00+hst per day

Parents MUST sign-up and pay in advance in order to receive extra care.

Notice of Warning:

There is a potential risk of injury involved in training and participating in any sport.  Spring Action has made every effort to create a safe and controlled environment for participation.  Rules, that must be followed, have also been established for participation and conduct on and about the training area.

 

_______________________________                               _______________

Signature of Parent or Guardian                                   Date