Rod Roy Online Registration Form (for Children & Teen programs)

1. Fill out the pertinent information.
2. Click the "Submit" button .
3. Print the confirmation page.
4. Pay via credit card using MiraPay secure online payment or by calling (514) 626-6240.
or
5. Pay via cheque to: (payable to Ski Rod Roy) and mail to:
Ski Rod Roy, 4435 Kingston, Pierrefonds, Quebec, H9A 2T2 (please write the member's name on the cheque).

* Required information
Please email or call (514) 626-6240 if you have any questions or concerns.

Personal Information: Email Address
* 		 
  Family Name
* 		First Name
* 		 
  Date of Birth
* dd/mm/yy

Citizenship

  
  Street Address
 City
  
  Postal Code
 Province
  
  Medicare Number
* 		Medicare Expiry Date
* yyyy/mm 		 
 
Home Phone Number
 * 		  Cell Phone Number (parent)
    *
Work Phone Number
  
  Emergency Contact Person (name & phone number)
Cell Phone Number (student)
 
  Parent's Name
 What school do you attend?
  
details Program
* 		Bus Stop
  
Registration Information: I am a...  
 
Former Member of Rod Roy?
 
 
For new members only:
For new members only:
 
 
 
  Are you interested in Terrain Parks? Friend Request - to be in the same class or at the same time as...  
       
 
Program Cost:
Federal Tax  
  Provincial Tax  
 
Subtotal:
  
 
Discount:
  
 
U.S. Medical Insurance: Yes: No:
($20 RR Max & Adult Sunday programs, $15 Ski à la Carte)
  (ages <59)  
 
Ski Patrol voluntary contribution:
 
 

Grand Total:

 
Credit card: Visa & M/C only
Method of Payment:
 *  
 
If paying by postdated cheques:

Amount:

 
 
Dates for postdated cheques:

1. On registration
2. December 1st.
3. January 1st.
4. February 1st.

  
 
Referred by:
  
  Comments

I have read and agree to the terms & conditions

Please check this box if you do not want your name published on web bus lists and class lists.

  
 

n.b. Form tested in Internet Explorer and Netscape 6.0
If you are experiencing difficulties please call (514) 626-6240.

Please submit your registration.