The Canadian Playground Safety Institute's Playground - Recreation ...

Canadian Playground Safety Institute Fall 2012 Registration Form forTHEORY / PRACTICAL COMBINED CERTIFICATION COURSESRegistrant InformationName: _______________________________________________________________________________________________________________Organization:______________________________________________________ Position: _____________________________________________Address: ______________________________________________________________________________________________________________City: _ _________________________________________________________________ Prov/Terr: _ _________ Postal Code: _ _______________E-mail: _ ____________________________________________ Work Phone: ________________________ Fax: _________________________Course Location Information (Registration deadline is Friday, October 5, 2012)Location Theory Dates Practical Dates Facility Info.p Dauphin, MB October 16-17 October 18-19Strilkiwski Room,Parkland Recreation Centre.200 1st St SE, Dauphin, MBRegistration Fees Mbr ($) Non-mbr ($) GST @ 5% Sub-totalTheory Course (Fee does not include exam) 400 425Theory Course Re-take (Fee does not include exam) 200 200Theory Exam 75 75Practical Course (Fee does not include exam) 450 475Practical Course Re-take (Fee does not include exam) 200 200Practical Exam Fee (p Check here if you are writing the recertification exam) 75 75Please Note:_Participants must have a provincial or territorial recreation association corporate orindividual membership to receive the member discount.Snacks will be provided during breaks, but lunch is not included in the registration fee.The re-take fee is only applicable to participants who have taken the course in the last12 months.If you are attending the Practical course only, you must bring your own copy of theCAN/CSA Z614-07. If you need to order one, contact CPSI by email: cpsi@cpsionline.caCourse Fees TotalGST # 81988 4057 RT0001Course hosted by:Payment InformationDauphin Recreation ServicesYour payment must be received by CPSI in advance of your course to complete the registration process and to obtain course materials.Credit Card: p MasterCard p VISA Card Number: _ ________________________________________________________ Expiry Date: ______________________Cardholder’s Name (Print): ________________________________________________________________ Signature: _____________________________________Cheque:Made Payable to: Canadian Playground Safety InstituteMail registration form and payment to: Canadian Playground Safety Institute, 8240C 31 Street SE, Calgary, Alberta, T2C 1J1CPSI CANCELLATION POLICYIF YOU CANCEL: All cancellation notices must be in writing. If CPSI receives a cancellation notice from the participant, five (5) business days or more prior to thestart of a course, a $150 cancellation fee will be retained for each of the Theory and Practical Courses. If a cancellation notice is received four (4) businessdays or less prior to the start of the course, there will be no refund. There will also be no refund for ‘no-show’ registrants.SHOULD CPSI CANCEL: Should CPSI be required to cancel a course, participants will be notified as soon as possible. CPSI is not responsible for costs alreadyincurred by the participants at the time of cancellation.If you have additional questions regarding CPSI’s cancellation policy, please contact the CPSI office at 1-877-536-2338.Please fax your completed registration form to CPSI at 1-403-203-0495