Dakota Development Camps 2006
Summer Day Camps Registration Form

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:    Position:    Health Insurance #:

Name of Parents/Guardian:    Email:

Health remarks/ special requests:

Program Choices:

1. Hockey & Sports Camps (Ages 5-12)

2. Power Skating Performance & Sports Camps (Ages 5-12)

3. Optimal Hockey Development Camps (Ages 8-17)

4. Optimal Goaltender Development Camps (Ages 8-17)

5. Ringette & Sports Camps (Ages 5-12)

Payment Method:     Number (no spaces):
Expiry Date (MM/YY):  /    Amount $ 

Camp Parental Consent and Waiver of Responsibility:  The applicant agrees that the Dakota Community Centre and it’s instructional staff will not be held responsible for any accidents or loss of personal property,  and agrees to release the Dakota Community from all claims or damages which may arise as a result of such accidents or loss.
Agree to Consent and Waiver above:

Consent to Collection,  Use and Disclosure of Personal Information:  I understand that, by completing this Form,  the Dakota Community Centre is collecting certain personal information about my child, me and other members of my Family (including if necessary, my Manitoba Health Services Registration Number).  I also understand that this personal information will be used only for the purpose of registering in the Dakota Community Centre’s Sports,  Recreational,  and Instructional Programs,  and that such use will necessarily involve the disclosure of this personal information to the appropriate area sport association(s) and/or the appropriate sport umbrella group(s),  coach(es) and manager(s),  and the use of such disclosed personal information by such association(s),  group(s),  coach(s) and manager(s) as may reasonably be required in order to conduct the Dakota Community Centre’s Sport,  Recreational and Instructional Programs. I hereby consent to such collection,  use and disclosure of this personal information.
Agree to Consent and Waiver above:

Enter your comments or special instructions in the space provided below:

 
Please contact me as soon as possible regarding this matter.

Copyright © 2006.  Dakota Community Centre.  All rights reserved.
Revised: January 10, 2007 .