Registration Form for 2015-2016 Season Main

Quinte Blades Speed Skating Club
Registration Form for 2015-2016 Season
Main Contact / Family Information
Alternate Contact / Family Information (optional)
Name
Phone
Email
Address
Name
Phone
Email
Address
Member
Type
DOB
Name
(DD/ MMM/ YYYY)
_Skater
_Associate**
___/____/_____
_Skater
_Associate
___/____/_____
_Skater
_Associate
___/____/_____
_Skater
_Associate
___/____/_____
_Skater
_Associate
___/____/_____
**1 Associate is included, additional Associates are $20.00
Skate
Rental
TOTAL #
Membership Fees
Individual (Ice + OSSA Registration + 1 Associate) -- $485.00
Four Session Trial (Ice + OSSA Registration + Rental) -- $80.00
Associate Member -- $20.00
Cost Calculation
___ x $485 Skating Members
___ x $20 Additional Associates
___ x $20 Skate Sharpening
___ x $110 Skate Rental
TOTAL
Pay by Cheque or Cash (You can split your payment three post dated amounts.)
Cheque 1
September 14, 2015
Amt:
#
Pay by Cheque Payment Schedule – Office Use Only
Cheque 2
Cheque 3
November 13, 2015
January 15, 2016
Amt:
Amt:
#
#:
Skate
Sharpening
Quinte Blades Speed Skating Club
PERMISSION and WAIVERS
(Parent or guardian if applicant is under 18/d’un parent ou tuteur si candidat a moins de 18 ans)
Skater’s Last Name_____________________________________
First Name(s):________________________________________________
CODE OF CONDUCT: Parents are expected to be present or responsible for the behavior of their
children while they are at practice and competitions. Skaters are expected to treat coaches, volunteers,
and other skaters with respect both on and off the ice.
(Please Initial)
MEDICAL CONSENT: I give consent for the Quinte Blades coach/supervisor to seek emergency
medical care for my child/ward if needed and I understand that the Quinte Blades will attempt to
contact me in case of a medical or other emergency.
Parent/Guardian’s NAME and Cell Phone # in case not in arena in the event of a skater injury:
_____________________________________________________________________
Family Doctor:_______________________ Phone#:_______________
Special Medical Concerns: (i.e. allergies, etc.)
PHOTO RELEASE : I hereby give permission for images captured during regular season and special
Speed Skating activities through video, photo and digital camera, to be used solely for the purpose of
the Quinte Blades Speed Skating Club promotional material and publications, and waive any rights of
compensation or ownership thereto.
Promotional Permission
Web Permission
WAIVER:
I hereby, for myself, my heirs, executers and assigns, waive and release any claim of damages that I
may have against the Quinte Blades Speed Skating Club and the City of Belleville or their agents.
Je déclare pour moi-même, mes héritiers, exécuteurs et délégués toute responsabilité et promet de ne
pas engager de poursuite pour dommages contre le club de patinage de vitesse Quinte Blades, la ville
Belleville ou leurs représentants.
Parent/Guardian’s NAME: _______________________________(please print)
Signature:__________________________ Date:_________________