Request for Recreational Program Refund

Request for Recreational Program Refund
Pickering Football Club Inc.

1975 Clements Road, Pickering, ON, L1W 4C2

Telephone: 905-831-9803 / Fax: 905-239-0067

Website: www.pickeringfc.ca
To be completed by PFC Member
Date of Request

MonthDayYear
Date
Requested by
Email
example@example.com
Cell Number

Area CodePhone Number
Home Number

Area CodePhone Number
Participant's Name
Participant's DOB
DD/MM/YYYY
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Season
Program
Refund Amount Requested:
Original Payment by
Refund cheque made payable to:
Payment Address
Alternate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Refund:
Confirmation of Injury - note from Doctor

Browse Files
(if an injury is listed as a reason for the refund request) Cancelof
Requested by Signature:
A copy of this application will be sent to your email as soon as possible.
PFC Office Use Only

To be completed by PFC Staff below this point
Ontario Soccer Participant Number

Club Fees

To be completed by PFC Member