General Program Application Form

Program: ---------------------------------------------                 Program Date: ---------------------------------

Address:-------------------------------------------------------------------------------------------------------------------

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Phone: home (       )                                  work (       )                                  fax (       )

Email: -----------------------------------------------------------

Age: -------------         Sex: -------------             Vehicle:  have own (   )    need transportation (    )

Comments (dietary needs, need rentals etc):-----------------------------------------------------------------------------------------------

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Prior experience (list separately if necessary): ---------------------------------------------------------------------------------------------

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How did you hear about this program? ---------------------------------------------------------------------------------

Cancellation Insurance:  (tick one)         p I do require             p I do not require

Payment,  please accept my: (tick one)        p Deposit                  p Payment in full

p Cheque/money order enclosed            p I wish to pay by credit card:     p Visa p MC

Credit Card Number: -----------------------------------------------      ExpiryDate:--------------

p Please use this credit card for final payment when due.

I have read the booking conditions and agree to them

Signature: ------------------------------------------------------------------------------ Date: -------------------