Last Name:    First Name:

Address:    City:  

Postal Code:    Community Club:

Phone (H):    Parent (W):    Emergency/Cell:

 Age:    Height:    Weight:  Lbs   Birth Date: DD    MM    YYYY 

 Gender: Select Male Female   Position:    Health Insurance #:

Name of Parents/Guardian:    Email:

Health remarks/ special requests:

Program Choices:

1. Optimal Power Skating Camps $95.00

Select Session S1: Ages 8-10, Sep 6-9, $95.00 S2: Ages 11-13, Sep 6-9, $95.00

2. Optimal Pre-Season Hockey Skills & Scrimmage Camps $199.00

Select Session S1: Ages 5-6, Aug 27 at 5:00PM, $199.00 S2: Ages 7-8, Aug 27 at 6:10PM, $199.00 S3: Ages 9-10, Aug 27 at 7:20PM, $199.00 S4: Ages 11-13, Aug 28 at 4:50PM, $199.00 S5: Ages 14-17, Aug 28 at 6:00PM, $199.00

3. Optimal Goaltender Development Camps $150.00

Select Session S1: Ages 7-10, Sep 8, 9, 15, 16, $150.00 S2: Ages 11-14, Sep 8, 9, 15, 16, $150.00

4. Optimal Performance Programs $85.00

  Select Session S1: Oct 3-Nov 21, $85.00 for 10 hours S2: Jan 9 - Feb 27, $85.00 for 10 hours

5. Optimal Defenseman Development Camp, $75.00

Select Session S1: Ages 8-11, Sep 12-14, $75.00 S2: Ages 12-14, Sep 12-14, $75.00

6. Optimal Shooting and Scoring Development Camp, $75.00

Select Session S1: Ages 8-10, Sep 15-16, $75.00 S2: Ages 11-13, Sep 15-16, $75.00 S3: Ages 8-13, Sep 15-16, $75.00

Payment Method: Select Card Visa Mastercard   Number (no spaces):
Expiry Date (MM/YY):  /    Amount $   

Parental Consent and Waiver of Responsibility:

1. I hereby authorize the Dakota Community Centre to take photographs of my child named in this application during camp activities, and to display and otherwise use these photographs without charge solely for the purpose of promotional material in connection with the Dakota Community Centre. 

2. I also understand that injuries can arise by accident from the very nature of Camp activities, and I hereby release and waive all rights to any claim or action against Dakota Community Centre arising from injury, loss or damage to my child or to my child's property except where such injury, loss or damage is caused by the negligence of the Dakota Community Centre. Select Agree Disagree

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