APPLICATION FORM

Burlington Fitness & Racquet Club

Kids SummerCamp
http://www.burlingtonfitness.ca

Participant Information

First Name *

Last Name *

Gender

Birth Date +

Household / Adult Primary Contact

First Name *

Last Name *

Address 1 *

Address 2

City *

Province *

Postal Code *

Phone

Alternate Phone

Email Address *

REQUIRED INFORMATION

SKILLS DEVELOPMENT PROGRAM

$400 + HST = $452.00 BFRC MEMBERS

$450 + HST = $508.50 NON-MEMBERS

MINI-TENNIS

$250 + HST = $282.50 BFRC MEMBERS

$275 + HST = $310.75 NON-MEMBERS

PAYMENT METHOD

Cash (in club only)

Cheque payable to Burlington Fitness & Racquet Club

Credit Card

Card Type

Visa

Mastercard

Amex

Credit Card #

Expiry Date mm/yy

Security Code

First Name *

Last Name *

Street Address *

Address Line 2

City *

Province *

Postal Code *

Phone Number *

AUTHORIZATION

By clicking the box I hereby acknowledge, agree and understand that the use of Fitness, Etc. Inc's faciliites, services and the Kids Club involves risk of injury ..... I hereby authorize Fitness Etc. Inc to charge my credit card for the amount selected above. *

I hereby authorize Fitness Etc. Inc to charge my credit card for the amount selected above.

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