GOLF REGISTRATION

*Indicates required fields.

Name*
 Agency
Street *

 City*
 Post Code / Zip Code*
 Province:*
E-mail Address*
 Telephone Number
  Fax Number
Place me on any team:
Place me with this golfer / team:
I have special dietary requirements
How many people: $115.00 per person
Credit Card Number
 Name on Card
Expiry Date
 Type of Card

Please pay by credit card or send cheque to address below.

Brain Injury Community Re-entry (Niagara) Inc.
261 Martindale Road, Units 12 & 13
St. Catharines, Ontario
L2W 1A1

Telephone: 905-687-6788
Toll Free: 1-800-996-8796
Fax: 905-641-2785
Email: staff@bicr.org