St. Vital Curling Club

CAMP CARRUTHERS
JUNIOR CURLING CAMP REGISTRATION FORM
Select week you would like to attend: / ☐ / Week of August 22 to August 26, 2016
☐ / Week of August 29 to September 2, 2016
Cost: $450.00 per curler ($225 due by June 30, 2016)

Curler Information

Full Name:
Last / First / Middle
Address:
Street Address / Apartment/Unit #
City / Province / Postal Code
Age: / Gender:
Years Curled: / Club Affiliation:
Cell Phone: / Home Phone:
MB Health (6 Digit) / MB Health (9 Digit)
Emergency Contact:

Additional Information

List any dietary concerns/allergies:

List any medical concerns:

Please be aware that video/photo(s) may be taken at the camp and may be used for publicity purposes.

☐ / I acknowledge that video/photo(s) may be taken/used.

Please submit this form via email to

Please mail your application and cheque (Payable to St. Vital Curling Club) to:

286 Regal Avenue

Winnipeg, MB R2M 0P5