2015 GAC SUMMER TENNIS CAMP REGISTRATION
FAMILY INFORMATION:
PARENT / GUARDIAN 1
First Name: _________________________
Last Name: _________________________
Home Phone: _______________________
Cell Phone: _________________________
Email: _____________________________
PARENT / GUARDIAN 2
First Name: _________________________
Last Name: _________________________
Home Phone: _______________________
Cell Phone: _________________________
Email: _____________________________
EMERGENCY CONTACT IS THE SAME AS PARENT/GUARDIAN: YES
NO
(IF ‘NO’ COMPLETE CONTACT INFO. BELOW)
EMERGENCY CONTACT: First Name: ____________________Last Name: ___________________
EMERGENCY PHONE: __________________
RELATIONSHIP TO CAMPER: __________________
PICK UP AT THE END OF CAMP DAY:
________________ Parent
_____________Other
If Other; First Name: ______________________ Last Name: _____________________
Phone: ________________________________ Relationship to camper: _____________________
CHILD 1
CHILD 2
FIRST NAME:
FIRST NAME:
______________________________
LAST NAME:
______________________________
ADDRESS:
______________________________
LAST NAME:
______________________________
ADDRESS:
POSTAL CODE: ____ - ____
POSTAL CODE: ________- ________
DATE OF BIRTH: M _____ D_____ Y _____
DATE OF BIRTH: M _____ D_____ Y _____
AGE: ____
AGE: ____
GENDER:
M
F
GENDER:
M
F
PLAYING EXPERIENCE:
BEGINNER
INTERMEDIATE/ADVANCED
PLAYING EXPERIENCE:
BEGINNER
INTERMEDIATE/ADVANCED
ALLERGIES / ILLNESSES:
ALLERGIES / ILLNESSES:
DIETARY RESTRICTIONS:
DIETARY RESTRICTIONS:
_____________________________________
HEALTH CARD NUMBER AND VERSION CODE:
_____________________________________
_____________________________________
HEALTH CARD NUMBER AND VERSION CODE:
_____________________________________
SPECIAL INSTRUCTIONS FOR CARE OF MY CHILD:
SPECIAL INSTRUCTIONS FOR CARE OF MY CHILD:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
2015 GAC SUMMER TENNIS CAMP REGISTRATION
CONSENT & RELEASE (Child)
I give permission for my child/children to participate in the Glendon Athletic Club
programs/camps and agree that York University, its employees, officers, Board of Governors and
agents will not be held responsible for any accident or loss however caused and agree to release
them from all claims and damages which may arise as a result of such accident or loss. In
signing this consent and release agreement, I hereby acknowledge that I have read and
understood the conditions and certify that my child is in good physical health and that there is no
medical reason why he/she should not attend.
Name of Child: First Name: ____________________ Last Name: ____________________
First Name: ____________________ Last Name: ____________________
Name of Parent/Guardian:
First Name: ____________________ Last Name: ____________________
Signature of Parent/Guardian: _______________________________________________
Date: ______________________
PHOTO PERMISSION FORM (Child)
I give permission for the use of any photos of my child/children taken while participating in any
Glendon Athletic Club program/camp to appear in a future brochure or other future
program/camp advertising.
Name of Child: First Name: ____________________ Last Name: ____________________
First Name: ____________________ Last Name: _____________________
Name of Parent/Guardian:
First Name: _________________ Last Name: _________________
Signature of Parent/Guardian: ___________________________________________________
Date: ______________________
2015 GAC PAYMENT AUTHORIZATION
CHILDS NAME: _____________________________________________________________________
TENNIS CAMP DETAILS:
After School Spring Starter Camp
Starter Camp: Wednesdays (May 13 – June 17)
4
Camp Dates (Please select):
Extended Care:
Yes
Junior Tennis Camp
Beginner: 6 – 7pm
Inter./Advanced: 7 – 8pm
5 DAY CAMPS:
J ULY 27 – 31
J UNE 22 – 26
AUG 10 – 14
J ULY 6 – 10
AUG 17 – 21
J ULY 13 – 17
AUG 24 - 28
J ULY 20 – 24
DAY CAMPS:
J UNE 29 – 3
AUG 4 – 7
No
Visit:
www.glendon.yorku.ca/gac
for more camp information
Annual
Member rate
(per week)
Monthly &
10% Member
Non-Member Rate Family Discount
(for each additional
(per week)
10% Non-Member
Family Discount
(for each additional
family member)
Starter Camp
Junior Tennis Camp (4 days)
Junior Tennis Camp (5 days)
Extended Care (4 days)
Extended Care (5 days)
$ 100
$ 240
$ 300
$ 36
$ 45
$ 120
$ 300
$ 375
$ 36
$ 45
$ 108
$ 270
$ 337.50
n/a
n/a
$
$
$
$
$
family member)
$ 90
$ 216
$ 270
n/a
n/a
Child 1 Camp Fees
Child 2 Camp Fees
Extended Care Fees
Subtotal
Total Fees
METHOD OF PAYMENT
□
VISA
□
MASTERCARD
□
Card Number:
_____________________________________________
Expiry Date:
________________________________
Security Code: _________
Card Holder Name: ________________________ Signature of Cardholder: __________________________
Membership Number (if appl.):________________
I hereby authorize the Glendon Athletic Club (York University) to charge my credit card in the amount of
$____________.
I understand that full payment is due upon registration.
MAIL/FAX REGISTRATIONS TO:
Glendon Athletic Club, 2275 Bayview Ave, Toronto, Ontario M4N 3M6
Attention: Aaron Rodrigues, Racquets Professional
Email: racquets@glendon.yorku.ca Fax: 416-487-6789