MAPLE BAY ROWING CLUB Junior Member Registration Form 2015/2016 Member Information LAST NAME: ___________________________ FIRST NAME(s):_______________________________ HOME ADDRESS: ____________________________________________________________________ (street address) (City) (Postal Code) GENDER (rowers only): M F BIRTHDATE (rowers only): ______________________(mm/dd/yyyy) ALLERGIES or MEDICAL CONDITIONS: ____________________________________________________________________________________________________________________________ PHONE NUMBER(s): Home: _________________________ Cell/Work: _________________________ EMAIL ADDRESS: ____________________________SCHOOL __________________________________ Associated Family Members____________________________________________________________ (If applying for a family membership) Note: 
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A separate form must be completed for each rowing member. A combined form is OK for non‐rowing family members. A family is up to two adults and registered rowing children.
Parent/Guardian Contact Information
Parent/Guardian Name :_______________________________E‐Mail: ________________________ Phone Numbers: (home)___________________(cell)_________________(work)________________ Parent/Guardian Name :_______________________________E‐Mail: ________________________ Phone Numbers: (home)___________________(cell)_________________(work)________________
Fees Calculation (All fees include GST) MEMBERSHIP DUES  Single Membership ‐ $40.00/year  Family Membership ‐ $60.00/year  Upgrade from Single to Family Membership ‐ $20.00/year  Family Membership Paid On Another Registration _____________ _____________ _____________ $ 0____ ROWING FEES (in addition to membership dues)  Novice Fall Fees ‐ $310  Novice Spring Fees ‐ $400 (includes regatta fees)  Junior Fall Fees ‐ $410  Junior Spring Fees ‐ $475 (includes regatta fees)  Mandatory Refundable Spring Ergathon Levy ‐ $100 _____________ _____________ _____________ _____________ _____________ _____________ TOTAL FEES DUE Payment Full Payment Received by: Deferred Payment Option Refundable Ergathon Levy  Cash  Cheque Rec’d by: ____________  See payment plan listed below  Cheque ($100 dated February 1, 2016) Payment and Waiver Form Received By: ___________________________ Date: ________________ PAYMENT PLAN FOR 2015‐2016 NOVICE/JUNIOR ROWING SEASON If you plan on using the Deferred Payment Option, please come to Registration Day (September 5, 2015) with 9 post‐dated cheques completed according to the payment plan below: FALL 2015 SEASON CHEQUE DATED CHEQUE # AMOUNT REC’D BY st
1 Registration Day $150 September 5, 2015 2nd October 1, 2015 $100 3rd November 1, 2015 $100 th
4 December 1, 2015 Novice: (not required) Junior: $100 SPRING 2016 SEASON CHEQUE DATED CHEQUE # AMOUNT REC’D BY 1st January 1, 2016 $100 nd
2 February 1, 2016 $100 3rd March 1, 2016 $100 th
4 April 1, 2016 $100 5th May 1, 2016 Novice: (not required) Junior: $75 NOTES: ‐
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AnyNSFchequewillresultina$50chargetothemember
November1–membershipnotingoodstandingifpaymentorproofofapplicationfor
financialassistancenotreceivedandrowingprivilegesmaybesuspended
MandatoryErgathonlevy($100)–separatechequedatedFebruary1(ergathonchequeswill
notbecasheduntilaftercompletionoftheErgathontoallowrowerstheopportunitytoobtain
pledgestooffsetthislevy).