Full Winter 2015 Reporter - Courtenay Recreation- optimized

Courtenay Recreation

MAIL: Lewis Centre, 489Old IslandHwy Courtenay, B.C. V9N 3P5 Filberg Centre, 411 Anderton Ave Courtenay, B.C. V9N 6C6

To register by FAXorMAIL, complete this form&send it in. Please call to confirm that your registrationhas been received. FAX: Lewis Centre, 250-338-8600

MainContact Information Name: ______________________________________________________ Birthdate: _______________ BCCareCard#: __________________________ Allergies/Medical Conditions: __________________ _____________________________________________________________________________________ MailingAddress: ______________________________________________ City: ___________________ Postal Code: ________________ Home Phone #: __________________ Work # : ________________ EMAIL _____________________ Family Doctor/phone #: __________________________________ FamilyMembers Name: _________________________________ Birthdate: __________________________________ BCCareCard#: __________________________ Allergies/Medical Conditions: __________________ _____________________________________________________________________________________ Name: _________________________________ Birthdate: __________________________________ BCCareCard#: __________________________ Allergies/Medical Conditions: __________________ _____________________________________________________________________________________ Name: _________________________________ Birthdate: __________________________________ BCCareCard#: __________________________ Allergies/Medical Conditions: __________________ ______________________________________________________________________________________

Registration Information

Participant’s Name: _____________________ Program: _________________________________ Time: ____________ Start Date: ______________ ProgramFee: $______________ Participant’s Name: _____________________ Program: _________________________________ Time: ____________ Start Date: ______________ ProgramFee: $______________

Participant’s Name: ____________________ Program: ________________________________ Time: ____________ Start Date: _____________ ProgramFee: $______________ Participant’s Name: ____________________ Program: ________________________________ Time: ____________ Start Date: _____________ ProgramFee: $______________

Courtenay Recreation

Registration

Total Fees: $ ____________ + 5%GST (if over 14 yrs) : $___________ = TOTAL: $ _______________

Payment: (Must be includedwith your registration) ( ) Cheque ( ) Visa ( ) MC Credit Card#: ___________________________________________ Expiry Date: _________________ Cardholder’sName: _____________________________________ Phone #: __________________________

115

Registration starts Wednesday November 19 see page 114