2016 BISON WOMENS' SOCCER TOURNAMENT

2016 BISON WOMENS’ SOCCER TOURNAMENT REGISTRATION FORM January 24, 2016 - Max Bell Fieldhouse 10 AM TO 4 PM Last Name: ____________________________________

First Name: _________________________________

TEAM NAME __________________________________________________________________________________ Date of Birth (day/month/year): __________________________________________________________________ Email: _________________________________________ Primary Phone Number: ___________________________ Address: ____________________________________________________________________________________ City: _______________________

Province: _____________________ Postal Code: _________________

□ I agree to allow The Faculty of Kinesiology and Recreation Management and Bison Sport at the University of Manitoba to contact me by email with information and updates regarding programs, memberships, services and facility information. I may withdraw my consent at any time by contacting Customer Service at 204.474.6100, 145 Frank Kennedy Centre, University of Manitoba, Winnipeg MB. R3T 2N2.

Dated:

__________________________________

Participant Name:

__________________________________

Participant Signature:

__________________________________

PLEASE FLIP FORM OVER FOR PAYMENT INFORMATION

2016 BISON WOMENS’ SOCCER TOURNAMENT REGISTRATION FORM January 24, 2016 - Max Bell Fieldhouse

_____ Student Team ($150)

Code:23809

Team Name _______________________________________________

_____ Student Individual ($15) Code: 23810

Student Number ___________ Player Position_____________________

_____ Community Team ($200) Code: 23811

Team Name ________________________________________________

_____ Community Individual ($20) Code: 23812

Player Position______________________________

Team Registrations should include a complete roster of players upon registration. Maximum of 12 players Payment Information Registrations can be dropped off at the Max Bell Customer Service counter or faxed to Customer Service 204-474-7503. All registration fees are non-refundable and due in full. Please review our refund policy at http://umanitoba.ca/faculties/kinrec/recreationservices/1255.html for more information.

Select One:

□ Visa

□ MasterCard

□ Cheque

Cheque # ________________________ (Payable to the University of Manitoba)

Credit Card Holder’s Name: _______________________________________

Credit Card Number: __________________________________________________

Expiration Date: _______/________ Total Amount Due :__________________ Authorized Signature: ______________________________________________ Processed By (CSR name and signature)__________________________________ Notice Regarding Collection, Use, and Disclosure of Personal Information by the University Your personal information is being collected under the authority of The University of Manitoba Act. The information you provide will be used by the University for the purpose of registering you for a Bison Sports program, and for communication regarding the program. Your personal information will not be used or disclosed for other purposes, unless permitted by The Freedom of Information and Protection of Privacy Act (FIPPA). If you have any questions about the collection of your personal information, contact the Access & Privacy Office (tel. 204-474-9462), 233 Elizabeth Dafoe Library, University of Manitoba, Winnipeg, MB, R3T 2N2