FALL 2004 LEARN TO DIVE REGISTRATION FORM - Etobicoke Diving Club

							                                            2012 SUMMER CAMP REGISTRATION FORM


Diver's Surname: _________________________                    Diver's Given Name: _________________________

Age: _______ Sex: ______               Date of Birth: _____________    Health Card #_________________________

Address (street, city, postal code): ____________________________________________________________

Parent's/Guardian's Name: __________________________________________________________________

Home Phone: _________________________                         Cell/Pager: _________________________________

Business Phone: ______________________                        Email Address: ______________________________

Family Doctor's Name and Phone #: ___________________________________________________________

Medical Concerns (allergies, medications, etc.): __________________________________________________

Emergency Contact Info. (name, number and relation): ____________________________________________



  WEEKS:                                                1. If class numbers are insufficient, you will be given the option
  (please circle the week you wish to attend)           of changing classes or refund of fees.
                                                        2. If you wish to cancel your participation, you must do so prior
  Mon - Fri 9:00 am- 3:00 pm                            to the first class. A $20.00 cancellation fee will be charged.
  Fee: $250.00                                          3. In an emergency, if parent or emergency designate cannot
                                                        be contacted, permission is given to the Etobicoke Diving Club
                                                        Inc. to seek medical assistance and treatment as may be
  Extended hours:                                       deemed necessary.
  3:00pm - 5:00pm ($50:00 extra)                        4. The Etobicoke Diving Club Inc. will attempt to provide every
                                                        safeguard to ensure the safety, health, and welfare of each
                                                        participant. The Etobicoke Diving Club Inc., all of its members,
  WEEK 1: July 2 – 6                                    directors, coaches, and instructors will be released from any or
                                                        all losses, damages, expenses, costs, claims, actions, and
  WEEK 2: July 9 - 13                                   demands of whatever nature arising from the participation of the
                                                        persons so named above in any and all programs stated on this
                                                        form.
  WEEK 3: July 16 - 20
                                                        Payment due upon registration by cash or cheque payable to :
  WEEK 4: July 23 - 27                                  Etobicoke Diving Club

  WEEK 5: July 30 - Aug 3
                                                        Signature of Parent/Guardian
  WEEK 6: Aug 7 - 11(Tue-Sat)

  WEEK 7: Aug 13 – 17
                                                        ______________________________ Date: _____________