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2010 Creative Wheel Centre Club Membership

We are happy to offer online registration this year. You must complete a form for every program participant.

NOTE: club membership is NOT mandatory for participation in any of our programs. We created this special membership due to the interest expressed last year to open the Centre on a weekly basis. If you wish to ride your mountain bike at the Centre, you need to join this membership.

If you wish to register by snail mail, you can complete this registration form and send with payment to:

177 Kehoe Street,
Ottawa, ON,
K2B 6A6

Thank you.

Any field that has a red outline is a REQUIRED field.

2010 Creative Wheel Centre Memberships

Choose a club option for yourself or your family.

Participation in any of our programs or memberships requires payment of QST, GST.
0 1 2 3 4 5	$150	Individual memberships
0 1	$250	Family memberships.
0 1 2 3 4 5	$100	65+ memberships.

Participants

Enter the details for each participant. Save $10 for each additional participant.

Participant #1 (primary contact)

First Name Last Name

	Year:	Month:	Day:
Date of Birth:	2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915	January/Janvier Febuary/Février March/Mars April/Avril May/Mai June/Juin July/Juillet August/Août September/Septembre October/Octobre November/Novembre December/Décembre	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Male Female
Participant #2
First Name Last Name

	Year:	Month:	Day:
Date of Birth:	2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915	January/Janvier Febuary/Février March/Mars April/Avril May/Mai June/Juin July/Juillet August/Août September/Septembre October/Octobre November/Novembre December/Décembre	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Male Female
Participant #3
First Name Last Name

	Year:	Month:	Day:
Date of Birth:	2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915	January/Janvier Febuary/Février March/Mars April/Avril May/Mai June/Juin July/Juillet August/Août September/Septembre October/Octobre November/Novembre December/Décembre	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Male Female
Participant #4
First Name Last Name

	Year:	Month:	Day:
Date of Birth:	2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915	January/Janvier Febuary/Février March/Mars April/Avril May/Mai June/Juin July/Juillet August/Août September/Septembre October/Octobre November/Novembre December/Décembre	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Male Female
Participant #5
First Name Last Name

	Year:	Month:	Day:
Date of Birth:	2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915	January/Janvier Febuary/Février March/Mars April/Avril May/Mai June/Juin July/Juillet August/Août September/Septembre October/Octobre November/Novembre December/Décembre	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Male Female

Contact

Please indicate how to contact you. You must provide telephone contacts, in case of emergency.

NOTE when entering a phone number, common formats are accepted. Some examples:

• 613 123 4567
• (613) 123-4567
• 613-123-4567 x8910

Home #	Work #	Emerg. #
Email Email (Re-Type)
Street Address 1
Street Address 2
City
Province	Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Country
Postal Code

Your personal and address information will not be shared with any third party without your prior concent. We do not store credit card information of any kind on our web site.

Medical Information

It is of critical importance that you advise us of any medical issues that might put you to risk during your participation. Please call us at 613.820.1919 if you have any allergies to insects (bees, wasps, hornets, spiders). All information is kept strictly confidential.

Release Waiver

I am aware of the inherent risks of bodily injuries and material damages possibly involved in the practice of this outdoor sport activity. I will follow the safety guidelines recommended in order to prevent any accident to myself and/or to the other participants. I hereby state that I am in good mental and physical health and I am not afflicted by any handicap that may endanger my participation in the activities proposed. Having registered for the above program, I hereby authorize LaRoccaXC Mountain Bike School and Club / Creative Wheel Consulting Inc. director and all of her appointees, volunteers and instructors, in the event of accident or illness affecting the above registered, to authorize on my behalf all procedures, including admission to hospital and necessary treatment therein, as deemed essential for the care and well-being of myself. Such action is to be taken only when immediate contact with myself, or emergency contact listed above, cannot be made. I understand that the pictures/videos/slides taken at the camp may be used for promotion. I have read and understood the refund policy and understand clearly that LaRoccaXC MTB Club / Creative Wheel Consulting Inc. will not be held responsible/liable for any lost, stolen or damaged belongings/sport equipment used by myself during my participation in the program.

I Agree to the terms and conditions.

Click the Register Now button to proceed to online payment.