Name    

Address    City    Province    Postal Code

Phone                 Additional Phone                   Email    

Please check the program(s) you are registering for.

Please use one registration per person. (once you have registered one person, please return to this form to register the next)

Day out with the Ladies of Breslau - Saturday October 2nd - 9am - 4pm - $30

BootCamp - Monday June 21st - August 16th - 7pm - 8pm - $45

Sweat 'n Sculpt - Thursday June 24th - August 19th - 6:30pm - 7:30pm - $45

Participant’s parents or legal guardians agree to hold Breslau Recreation Association, its Officers and Directors and their heirs and assigns, free and blameless of any damage, accident or injury which may occur to the participant while participating in Breslau Recreation Program. The participant understands that he/she is responsible for ensuring his/her personal safety during the program. MEDIA EXPOSURE The child(ren) listed on the Participant Form may appear in any publicity arranged by the Breslau Recreation Association, through the various media, newspaper, radio, television, slide presentations and other publications. **If you do not wish to have your child in program publicity, please stroke out this section and initial.

In the event of accident or illness involving my child(ren) while attending the program; I hereby authorize, if I am not immediately available, my permission for my child(ren) to be transported to the hospital by ambulance, and if required the administration of any medical procedure deemed necessary by the physician at the hospital.

To the extent that the foregoing information constitutes personal information under the Municipal Freedom of Information and Protection of Privacy Act, 1989, the information is collected under the authority delegated to the Township of Woolwich by virtue of the Revised Statutes of Ontario and will be used for the purposes indicated or implied by this form. Questions about the collection of personal information should be directed to Clerk, Township of Woolwich, Box 158, 24 Church Street West, Elmira, Ontario, N3B 2Z6. Phone 519-669-1647.

Cancellations

Requests for refunds must be made by, 7 days before the start date of the Program. Participants who withdraw during a program, for medical conditions only will be issued a refund. Participants who withdraw during a program for any other reason other than medical will not be issued a refund. ALL refunds/credits are subject to an administration fee

I Agree

By typing your name here, you are signifying your agreement to the above. Name

I Don't Agree

Please note: You will not be considered fully registered until you have paid.

You may pay by cheque or, now you may pay via PayPal on this site! (after you register, you will be presented with a button to select your payment which will then take you to the PayPal secure site)