Camps & Clinic Registration

You can securely register for a Summer Camp online with a valid Visa or Mastercard or you can submit a printable registration form by either fax or postal mail.

If you wish to register with me by postal mail or prefer to fax in a registration form to me, please print this page. If your are going to be paying by check, please make all cheque's payable to "Paul Cohen".

** Please complete ALL the form fields below. **

Summer Camps

Jun 16 to June 20 - Tampa, Fla

Aug 11 to Aug 15 - Ajax, Ont

Camp Level

Regular Junior or Senior Showcase

Pre and Post Camp Learning Tool

Instructional Software
(All three Cd's in 1)

The Ultimate Goaltending 3 CD Bundled Set

$99.95

Credit Card Payment

Payment Method

Credit Card Number

CVN number
(what is a CVN?)

Name on Card

Billing Address - Street

Billing Address - City

Billing Address - Province / State

Billing Address - Country

Billing Address - PC / Zip

Email Address

Personal Info

Student Name:

Birth date:

Parent / Guardian Name:

Address

City:

Province / State:

Postal / Zip Code:

Country:

Telephone:

Fax:

Previous Team and Level

Team & Level for 2006-2007:

Team & Level for 2007-2008:

Would you like to be contacted by..

Email:

If different from above

Phone:

If different from above

Fax:

If different from above

Best time to call: a.m. p.m.

You are almost done!

Referred by..

General Comments:

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