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 *

Month Day Year
Date
Requested by *
Email *
example@example.com
Cell Number *

Area Code Phone Number
Home Number

Area Code Phone Number
Participant's Name *
Participant's DOB *
DD/MM/YYYY
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Season *

Indoor Boys Indoor Girls Outdoor Boys Outdoor Girls Adult (Over 18)
Program *

Recreational All Abilities Camp or PA Day Adult or Community Programming Other
Refund Amount Requested: *
Original Payment by *

Visa M/C AmEx Cash Debit
Refund cheque made payable to: *
Payment Address *

Same as Above Alternate Address
Alternate Address

Street Address

Street Address Line 2

City State / 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) Cancel of
Requested by Signature: *

Clear
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