2010 Adult Mini Camp Registration Form

*Please make cheques and money orders payable to EDGES PSI and mail them
along with this form to:

Edges P.S.I.
13017 - 137A Street
Edmonton, Alberta
T5L 5A3

*or complete credit card information below and email form to coleytr@telusplanet.net

GST Reg #: 88216 5723 RT0001

CLASS : ADULT MINI CAMP

NAME:_____________________________________________

ADDRESS:____________________ CITY:________________ POSTAL CODE:____________________

BIRTHDATE(mm/dd/yy):_________________ PH: (H)__________________ (W)___________________

PREVIOUS SKATING/PLAYING EXPERIENCE:____________________

INJURIES OR HEALTH CONCERNS:_____________________________________________________

HEALTH CARE #:___________________________ EMAIL ADDRESS__________________________

HOW DID YOU FIND OUT ABOUT US?___________________________________________________

TOTAL COST(With GST): $________________

PAYMENT: Cash/Cheque Enclosed_______(*A $25 fee will be charged for all returned cheques)

Visa_____ Mastercard_____ Card #__________________________________ Expires_____________

Cardholder Name______________________________ Authorizing Signature____________________

No refunds or credits will be issued unless the program is cancelled by Tammy Coley or Superskate Advanced Hockey Development Association.
In consideration of the benefits awarded to us by acceptance of this application, the under signed agrees to save and hold harmless and
release Tammy Coley, Superskate Advanced Hockey Development Association, all coaches and assistants, and any private or municpal
rink of and from any and all claim rising from bodily injury and property damage sustained by the student. All skaters must wear helemts.

DATE:____________________ SIGNATURE ____________________________