ESTEVAN, SASKATCHEWAN, CANADA REGISTRATION FORM (REGISTRATION DEADLINE MAY 31, 2015) FLECKS CANADIAN SUPERCAMP Name _____________________________ LAST Parent _________________________ FIRST Address_______________________________________________________________________ CITY PROV POSTAL CODE EMAIL _______________________________ Phone _____________________________ Birthdate _______________________ MONTH _______ _______ _______ DAY Skater Camp _______ July 20 – July 25 $525.00 August 3 – August 8 $525.00 $475.00 $525.00 $150.00 $150.00 $10.00 Goaltender Camp _______ _______ (all fees include GST) Jersey Size (Circle) Youth M Name_______________________ ___ ___ ___ ___ ___ Position__________ Last Team_____________ YEAR L July 27 – August 1 $525.00 Shooters (9 yrs & up) $150.00 XL Adult S M No. _______________ L XL 2XL Early Bird - Full Payment by Feb 15/15 No late payments accepted. Full Payment after Feb 15/15 or Deposit enclosed ____ Balance post dated June 30, 2015 Shooter Session Personalized jersey ____ $20.00 FlxFit Socks – Height ________* * Flx Fit Socks are the custom socks(optional) that are made to match the jersey the participant receives at the camp. Due to the stretch feature of these socks the full height of the participant is needed for a proper fit. Make checks payable to: Flecks Hockey _____ Visa ______ Mastercard Card No: ______________________________ Credit card payment for full amount. Expiry Date ____ ___ Month Year CRV _________ 3 nos. off back Cardholder Name: ___________________________ Health Care # Medical Information: List any food allergies: CANELLATION AND REFUND POLICIES - A $150 deposit must accompany all applications. Balance of fee must be paid by June 30, 2015 - There will be no refunds or cancellations after 6/30/15 unless it is for medical reasons. In such a case, a Doctor’s certificate must be presented to verify the condition - There will be a $50 non-refundable service charge for ALL cancellations - If a player does not attend, or leaves during the week there shall be no refund. I/WE the undersigned being the parent(s) or guardian(s) of the above named player do hereby consent to the said child participating in all the activities of this hockey school and do hereby release, absolve and indemnify all coaches and staff of Flecks Hockey Inc. from any claim which I/ We, or the said child may have as a result of his participation. I/We do assume all risks and hazards incidental to the above article and hereby waive all claims whatsoever against the above named company or individuals. Signature of Parent or Guardian: FOR MORE INFORMATION: Allan or Peggy Fleck Cell (306)577-9872 Fax (306)577-4749 email: [email protected] Mail form with payment to: Flecks Hockey Box 902, Carlyle, SK S0C 0R0 Canada