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*

Indoor BoysIndoor GirlsOutdoor BoysOutdoor GirlsAdult (Over 18)
Program*

RecreationalAll AbilitiesCamp or PA DayAdult or Community ProgrammingOther
Refund Amount Requested: *
Original Payment by*

VisaM/CAmExCashDebit
Refund cheque made payable to:*
Payment Address*

Same as AboveAlternate 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:*

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