GOALIE INFORMATION

Student First Name *

Student Last Name *

Contact Email 1 *

Contact Email 2

Student Birth Date * +

Gender *

Summer Camp Year *

Medical Coverage Number

Parent/Guardian Name *

Medical Conditions/Medications/Allergies

How did you hear about us?

Has anyone referred you?

ADDRESS INFORMATION

Street Address *

City *

State/Province/Region *

Zip/Postal Code *

Home Phone Number *

Mobile Phone Number

Country *

Please select a camp below. Prices do not include GST

Pitt Meadows, BC: August 2-6, 2021 Location: Pitt Meadows Arena Complex

Goalie Jersey Size

League Level of Play *

Current Level of Play *

Returning Student *

GITN Camps (Years) *

Payment Options *

Full Payment

50/50 (50% at time of deposit/balance due June 1st)

4 Equal Payments (On or Before June 1)

Monthly Payment Plan - 1st of the Month (On or Before June 1)

Camp Refund Option (5% of camp fees) *

Yes

Name on Card

Credit Card Type

CVV Number

Credit Card Number

Expiration Date (mm/yy)

Credit Card Billing State/Postal Code

Enter the word in the image. *
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