City Mosaic 2016 Registration Form - Across U-hub

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City Mosaic Registration 2016

1 General Team

2 Team Leader Info

3 2nd Member Info

4 3rd Member Info

5 4th Member Info

6 Payment Info

General Team Information
Team Name*
Division*
- Adventurer (Full Race)
- Explorer (Half Race)
Information Session*
- Session 2: May 18, 2016 (Wed); 8:30pm – 9:30pm

Team Leader Information
Are you a member of Across U-hub?*
- Yes, I have already jointed Across U-hub membership.
- Not yet. I want to join Across U-hub membership now. I consent to receive email communication from Across U-hub.
Name*
First Last
Email*
Enter Email Confirm Email
Cell Phone*
Gender*
- Male
- Female
Home Phone*
Date of Birth*
MM
DD
YYYY
Address*
Street Address City Province Postal Code
Country of Birth*
Ethnicity*
Have lived in Canada since:*
MM
DD
YYYY
How did you know about this program ?*
- Friend
- Parent
- Booth
- Poster/Flyer
- Radio/TV/Newspaper
- Social Media
T-shirt Size*
- S
- M
- L
- XL
Emergency Contact Person*
Relationship
Emergency Contact Cell Phone*

2nd Member Information
Are you a member of Across U-hub?*
- Yes, I have already jointed Across U-hub membership.
- Not yet. I want to join Across U-hub membership now. I consent to receive email communication from Across U-hub.
Name*
First Last
Email*
Enter Email Confirm Email
Cell Phone*
Gender*
- Male
- Female
Home Phone*
Date of Birth*
MM
DD
YYYY
Address*
Street Address City Province Postal Code
Country of Birth*
Ethnicity*
Have lived in Canada since:*
MM
DD
YYYY
How did you know about this program ?*
- Friend
- Parent
- Booth
- Poster/Flyer
- Radio/TV/Newspaper
- Social Media
T-shirt Size*
- S
- M
- L
- XL
Emergency Contact Person*
Relationship
Emergency Contact Cell Phone*

3rd Member Information
Are you a member of Across U-hub?*
- Yes, I have already jointed Across U-hub membership.
- Not yet. I want to join Across U-hub membership now. I consent to receive email communication from Across U-hub.
Name*
First Last
Email*
Enter Email Confirm Email
Cell Phone*
Gender*
- Male
- Female
Home Phone*
Date of Birth*
MM
DD
YYYY
Address*
Street Address City Province Postal Code
Country of Birth*
Ethnicity*
Have lived in Canada since:*
MM
DD
YYYY
How did you know about this program ?*
- Friend
- Parent
- Booth
- Poster/Flyer
- Radio/TV/Newspaper
- Social Media
T-shirt Size*
- S
- M
- L
- XL
Emergency Contact Person*
Relationship
Emergency Contact Cell Phone*

4th Member Information
Are you a member of Across U-hub?*
- Yes, I have already jointed Across U-hub membership.
- Not yet. I want to join Across U-hub membership now. I consent to receive email communication from Across U-hub.
Name*
First Last
Email*
Enter Email Confirm Email
Cell Phone*
Gender*
- Male
- Female
Home Phone*
Date of Birth*
MM
DD
YYYY
Address*
Street Address City Province Postal Code
Country of Birth*
Ethnicity*
Have lived in Canada since:*
MM
DD
YYYY
How did you know about this program ?*
- Friend
- Parent
- Booth
- Poster/Flyer
- Radio/TV/Newspaper
- Social Media
T-shirt Size*
- S
- M
- L
- XL
Emergency Contact Person*
Relationship
Emergency Contact Cell Phone*

Billing Information
Billing Name
First Last
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing Email
Enter Email Confirm Email
Billing Phone
City Mosaic :
City Mosaic 2016
Price: $ 120.00 CAD
Promo Code (if applicable)
Total
$ 0.00 CAD

Tel:	+1 (905) 944-1944
Fax:	+1 (905) 944-1950
E-mail:	[email protected]
Address:	232 Hood Road, Markham, Ontario, Canada, L3R 3K8 (map)
Hours:	Monday-Friday: 10:00 AM-6:00 PM

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Across U-hub is a registered Canadian Charity # 849466164 RR0001
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