APPLICATION FORM

SUPER SUMMER CAMP 2009

Fill out this form, print it, sign it and mail it in with your cheque payable to :
Panthers Gymnastics Club
1016 Marion Street, Winnipeg, MB. R2J 0K8           Ph: 233-0187        Fax: 235-1850

Refunds will be provided for cancellations made up to 7 days prior to program start date.

A $35.00 administrative fee is applied to all cancellations.

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"FULL DAY CAMP" From 8:30am to 4:30pm  (check weeks attending)

FEES: $140.00 per week
          ($120.00 for the week of Aug. 4^th) The gym is closed on August 3^rd .
New Members must add a $15.00 membership fee (non refundable)

JULY JULY 6^th JULY 13^th JULY 20^th JULY 27^th

AUGUST AUGUST 4^th AUGUST 10^th AUGUST 17^th AUGUST 24^th

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"1/2 DAY CAMP" (check weeks attending)

Morning 9am-12 noon   or   Afternoon   1:30pm-4:30pm

FEES: $80.00 per week
           ($65.00 for the week of Aug. 4^th) The gym is closed on August 3^rd .
New Members must add a $15.00 membership fee (non refundable)

JULY JULY 6^th JULY 13^th JULY 20^th JULY 27^th

AUGUST AUGUST 4^th AUGUST 10^th AUGUST 17^th AUGUST 24^th

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SUPER SUMMER CAMP 2009

CHILD'S NAME

AGE BIRTH DATE: M D Y BOY GIRL

MOTHER'S NAME

FATHER'S NAME  

E-MAIL ADDRESS

ADDRESS: POSTAL CODE:

HOME PHONE WORK PHONE CELL PHONE

ALTERNATE PHONE (for possible emergency) NAME

MANITOBA MEDICAL NO. REGISTRATION #

KNOWN ALLERGIES:

OTHER CONDITIONS:

EPIPEN / INHALER:

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I WILL NEED EARLY DROP-OFF and / or LATE PICK UP SERVICES
PLEASE, SPECIFY
         PARENT’S SIGNATURE  DATE

I FOUND OUT ABOUT THIS CAMP FROM:

Cheque Enclosed Verified by


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