PARTICIPANT REGISTRATION FORM - 2013

Ciociaro Club Youth Cycling Program (WWW.CCKCP.COM)

Meetings & Events: (Tentative Dates)

Dates: June 3rd & 17th, July 8th 22nd, August 12th & 26th
Open to kids aged 6 – 15 (FREE MEMBERSHIP WITH SMILE)
Mandatory equipment: helmet, bike, running shoes and sense of adventure!
Registration/sign-in: at 6:00 pm before each session
1hr sessions: 6:15 – 7:15 pm
Last session (Aug 26th): Pizza party for kids, parents, & coaches
Feel free to go into the Ciociaro Club’s Member’s lounge after practice for their famous pizza. On Wednesday and Thursday evenings, it is buy one pizza, get the second one half price!

Primary Division (Gr. 1- 3 ) ages 5-8 yrs.
Junior Division (Gr. 4- 6 ) ages 9 - 11 yrs.
Intermediate Division (Gr. 7-8) ages 12 - 13 yrs.
Senior Division (Highschool) ages 14- 16 yrs.

Parents/ Guardians:

Please fill out the forms below to enable us to provide the best care for your child(ren). All information will be kept private and shredded once the cycling program is complete. Feel free to speak to Kevin Larkin or Rosemary Barbera should you have special concerns you want to share privately.

INFORMATION ABOUT PARENT / GUARDIAN:

FULL NAME OF PARENT / GUARDIAN:

HOME PHONE (eg. 123-456-7890):    CELL PHONE (eg. 123-456-7890):

GUARDIAN'S EMAIL ADDRESS:

ALTERNATE CONTACT (FULL NAME):

HOME PHONE (eg. 123-456-7890):    CELL PHONE (eg. 123-456-7890):

INFORMATION ABOUT PARTICIPANT:

FULL NAME OF PARTICIPANT:

GENDER:   Female    Male       AGE:       DATE OF BIRTH (YY/MM/DD):

GRADE LEVEL AS OF JUNE 2012:       SELECT DIVISION ACCORDING TO CHART ABOVE:

EMAIL ADDRESS:    PHONE (eg. 123-456-7890):

HOME ADDRESS:    CITY:    POSTAL:

OHIP #: (only for participants 16 yrs. and older with no adult present)

RELEVANT MEDICAL HISTORY:

MEDICATION:

ALLERGIES:

PREVIOUS INJURIES:

DOES THE PARTICIPANT CARRY AND KNOW HOW TO ADMINISTER HIS/HER OWN MEDICATION?     Yes    No

OTHER RELEVANT INFORMATION? (CONTACTS, BRACES etc...)

PLEASE PRINT AND FILL OUT THIS WAIVER FORM AND BRING IT WITH YOU TO THE CCKCP EVENT CCKCP WAIVER FORM

3745 NORTH TALBOT ROAD, OLD CASTLE, ONTARIO NOR 1LO

519-737-6153 ph 519-737-7269 fax www.ciociaroclub.com