Cross Country Alberta Program Registration Form
Use this form for registration in all CCA Programs
A) INFORMATION: (Please print)
Name: | Date of Birth: (y/m/d) | |||||
Street Address: | City/Town: | |||||
Province: | Postal Code: | FAX #: | ||||
Home Phone: | Work Phone: | |||||
e-mail: | Club Name: | |||||
Program Registered For: | ||||||
Fee Enclosed: $ | Cheque #: | |||||
Alberta Health Care #: | ||||||
Family Doctor Name / Phone Number: | ||||||
Important medical conditions? If yes, please attach details on separate sheet of paper. | ||||||
Emergency Contact Name / Number: |
B)DECLARATION:
I wish to (let) - (print name) participate
in. I have read the supplementary regulations issued for this activity and agree to be bound by them. In consideration of acceptance of this registration or of my permitting to take part in this program, I agree to save harmless and keep indemnified, Cross Country Canada, Cross Country Alberta, Organizers and the respective agents, officials, servants and representatives from and against all claims, actions, costs and expenses and demands in respect to death, injury, loss or damage to my personal property, however caused, arising out of or in connection with my (their) taking part in this program and not withstanding that the same agents, officials, servants or representatives. It is understood that this Agreement is to be binding on myself, my heirs, executors and assigns.
Participant's Signature:________________________________________Date:_______________________
Signature of parent*:__________________________________________Date:______________________
*If participant is under 18 years of age
Mail this form (completed) with cheque for program fees to: |
Cross Country Alberta - 11759 Groat Road - Edmonton, AB - T5M 3K6 |
CCA Phone Number: 780-415-1738 / Fax #: 780-427-0524 |