Cross Country Alberta Program Registration Form

Use this form for registration in all CCA Programs

• Complete the registration form below. Make cheque payable to Cross Country Alberta.
• Mail FORM AND PROGRAM FEE to: 11759 Groat Road, Edmonton, AB T5M 3K6
• In the case of last minute registrations please fax (780-427-0524) in a copy of a completed cheque, a completed registration form, and then send the originals to the address as described above.
• Registrations should be received 7 days prior to the commencement of the program. In the case where this isn’t possible due to special circumstances, please follow the procedure as described in point number 3 above, or bring form to course.

  A) INFORMATION: (Please print)

  Name:				Date of Birth: (y/m/d)
  Street Address:			City/Town:
  Province:	Postal Code:					FAX #:
  Home Phone:		Work Phone:
  e-mail:		Club Name:
  Program Registered For:
  Fee Enclosed: $					Cheque #:
  Alberta Health Care #:
  Family Doctor Name / Phone Number:
  Important medical conditions? If yes, please attach details on separate sheet of paper.
  Emergency Contact Name / Number:

  B)DECLARATION:

  I wish to (let) - (print name) participate

  in. I have read the supplementary regulations issued for this activity and agree to be bound by them. In consideration of acceptance of this registration or of my permitting to take part in this program, I agree to save harmless and keep indemnified, Cross Country Canada, Cross Country Alberta, Organizers and the respective agents, officials, servants and representatives from and against all claims, actions, costs and expenses and demands in respect to death, injury, loss or damage to my personal property, however caused, arising out of or in connection with my (their) taking part in this program and not withstanding that the same agents, officials, servants or representatives. It is understood that this Agreement is to be binding on myself, my heirs, executors and assigns.

  Participant's Signature:________________________________________Date:_______________________

  Signature of parent*:__________________________________________Date:______________________

  *If participant is under 18 years of age

  Mail this form (completed) with cheque for program fees to:

  Cross Country Alberta - 11759 Groat Road - Edmonton, AB - T5M 3K6

  CCA Phone Number: 780-415-1738 / Fax #: 780-427-0524