2011 - 2012 Superskate - "Learn To" 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 fax form to (780) 454-8400 or email to coleytr@telusplanet.net

GST Reg #: 88216 5723 RT0001

2011 - 2012 Superskate - "Learn To" Registration Form

_____ Class 1 Learn to Skate (Mondays 3:45 - 4:15 p.m. Castledowns)

_____ Class 2 Learn to Hockey (Mondays 4:15 - 4:45 p.m. Castledowns)

_____ Class 3 Learn to Skate (Tuesdays 3:45 - 4:15 p.m. Clareview)

WEEKS(Circle): 10 WEEKS / 20 WEEKS

NAME:_____________________________________________

ADDRESS:____________________ CITY:________________ POSTAL CODE:____________________

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

PARENT'S NAME(S):__________________________ PREVIOUS EXPERIENCE:___________________

INJURIES OR HEALTH CONCERNS:_____________________________________________________

HEALTH CARE #:___________________________ EMAIL ADDRESS__________________________

HOW DID YOU FIND OUT ABOUT US?_________________________

CLASS(ES):___________________ 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 Superskate Advanced Hockey Development Association or Edges Professional Skating Instruction (Tammy Coley). In consideration of the benefits awarded to us by acceptance of this application, the under signed agrees to save and hold harmless and release Superskate Advanced Hockey Development Association, Edges Professional Skating Instruction, Tammy Coley, all coaches and assistants, and any private or municpalrink of and from any and all claim rising from bodily injury and property damage sustained by the student. All skaters must wearCSAApproved Helmets for Learn to Skate Classes and full CSA Approved hockey equipment for Learn to Hockey classes.

DATE:____________________ SIGNATURE (Parent or Guardian):____________________________