T. Hayes Canadian Guiding Services
Box 532
Minitonas, Manitoba
R0L1G0
Phone: 1-204-525-4552
Program Information
Hunting Trip : a. (circle)
Rifle/Archery/Muzzleloader
b. (circle) Bear / Whitetail / Moose / Waterfowl
Do you shoot? a. (circle) Right / Left
Fishing: a:(circle) Angling
/ Icefish
Species:______________________________
Eco-Tourism: (circle)
Hiking / survival trip / Canoe / Motorboat / photography
other- specify:______________________________
Dates: from __________ to __________
Personal Information
Name: ______________________________
Address: ________________________________________
Home Phone: ____________________
Work Phone: ____________________
FAX: ____________________
E-Mail: ____________________
Age: _____
Sex: _____
Height: _____
Weight: _____
How did you hear about
us?
Medical / Health Information
Dietary restrictions:
Allergies, medical conditions,
physical limitations, current medications, etc:
Please give a brief but
accurate description of your general health and weekly activity level:
I affirm that my health is good and that the above information is accurate and complete.
Signature:
In Case of Emergency
Contact person’s name:
______________________________
Relationship: _______________
Home phone: ____________________
Work phone: ____________________
Health insurance carrier:
_________________________
Policy number: ____________________
Experience
Describe your outdoor experience
relevant to this program:
Payment
A nonrefundable deposit
of 30% of the program cost must accompany your registration form. Cheques
should be made payable to Toni Hayes c/o T. Hayes Canadian Guiding Services
Balance of program cost
30 days prior to program date.
Program cost: $__________
Amount enclosed (deposit
of 30%): $__________
|
