Provincial Championship Medal Claim Form

The medal claim form is for athletes who were unable to attend the medal ceremony at the Provincial Championship in order to receive their medal. Medals will be shipped within 5 business days.

Athlete Name*

First Last

Athlete Club Affiliation*

Athlete Email*

Enter Email Confirm Email

Delivery Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medal Delivery Method*

Total

CAD$ 0.00 CAD

Payment Information

Cardholder Name*

First Last

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Cardholder Email*

Enter Email Confirm Email

Cardholder Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Payment Information

Title