Driver Name _________________________________________________
Address _________________________________________________
City ____________________ Prov ________________________
Postal _____________ Phone __________________________
Parent/Emergency Contact _______________________________________
Membership Exp. Date ___________________
Storage: Starts_____________Expires________
___ Unlimited Practice Membership $ 500.00 Plus Tax
___ 30 Visit Practice Membership $ 375.00 Plus Tax
___ 15 Visit Practice Membership $ 250.00 Plus Tax
___ Drop in Passes $ 50.00 Plus Tax
___ 1 Year Storage Fee $ 450.00 Plus Tax
___ 3 Month Storage Fee $ 125.00 Plus Tax
___ 1 Year Insurance ($500 deductible) $ 100.00 Plus Tax
* Note – All memberships expire one year from the date of purchase.