Diver's Surname:           Diver's Given names:      

Age:          Sex:      Date of Birth:      

Address (street, city, postal code}:      

 Parent's/Guardian's Name:      

Home Phone:           Cell/Pager:      

Business Phone:           Health Card #:      

E-mail Address:      

Family Doctor's Name & Phone number:      

Medical Concerns (allergies, medication, etc.):         

Emergency Contact (name, number and relationship):      

1. Weekly fee is $250. If class numbers are insufficient, you will be given the option of changing classes or refund of fees.
2. If you wish to cancel your participation, you must do so prior to the first class. A $20.00 cancellation fee will be charged.
3. In an emergency, if a parent or emergency designate cannot be contacted, permission is given to the Etobicoke Diving Club Inc. to seek medical assistance and treatment as may be deemed necessary.
4. The Etobicoke Diving Club Inc. will attempt to provide every safeguard to ensure the safety, health and welfare of each participant. The Etobicoke Diving Club Inc., all of its members, directors, coaches, and instructors will be released from any and all losses, damages, expenses, costs, claims, actions, and demands of whatever nature arising from the participation of the persons so named above in any and all programs stated on this form.

Week Dates (please select the class day and time you would like to attend): . . . . . . . Choose Week 1) July 4 to 8 2) July 11 to 15 3) July 18 to 22 4) July 25 to 29 5) Aug 2 to 6 6) Aug 8 to 12 7) Aug 15 to 19 8) Aug 22 to 26 9) Aug 29 to Sep 2