FIS Registration Pac.. - Grouse Mountain Tyee Ski Club

BC ALPINE SKI ASSOCIATION
FIS REGISTRATION PACKAGE
2014-2015 SEASON
Online registra!on is required
h"p://registra!on.bcalpine.com
Any clubs that are unsure of online registra!on
process, please contact Keven Dubinsky
at the BC Alpine Office for
direc!ons and access to this system.
IMPORTANT DISCLAIMER:
Individuals must register directly with their club not with BC Alpine.
Always default to your club’s guidelines which may have earlier !melines, different costs and requirements than we list here.
MANDATORY REQUIREMENTS FOR REGISTRATION OF FIS ATHLETES:
1.
2.
3.
4.
5.
FIS registra!ons must come from a BC Alpine member club, not directly to the BC Alpine office.
Registrants must be Canadian ci!zens.
Athlete must be a member in good standing with BC Alpine with no outstanding payments due to any of our member clubs.
Club registrar has submi#ed all per!nent informa!on on line through the BC Alpine database previous to forwarding paperwork.
All original copies (ink on paper) of completed Registra!on Forms must by at BC Alpine office by registra!on deadline.
IMPORTANT THINGS TO CONSIDER:
A. The FIS Medical Form requires a visit to your doctor’s office, which generally will incur addi!onal costs and should be booked
ASAP to avoid delays and a poten!al late fee.
B. Any registra!ons that do not have paperwork in to the BC Alpine Office by the September 20th deadline will be automa!cally
assessed the “Late Registra!on” fee.
C. If the member is not properly registered by their club online, the membership forms will not be accepted by BC Alpine.
D. It is the responsibility of the athlete to ensure their name appears on the FIS site with ac!ve status prior to their first FIS race.
E. Faxed, emailed or scanned forms will not be accepted under any circumstance.
CANCELATION POLICY:
DISCIPLINE SELECTION:
FIS Registra!ons may be canceled by Oct 15th
but will be subject to a $55.00 cancella!on fee. A#er Oct 15th membership
may not be canceled or refunded.. BC Alpine must be informed by email
([email protected]) of all requests to remove a FIS registra!on. BC Alpine
has no control over FIS deadlines or late fees.
FIS Athletes may select to be either Alpine,
Skicross or both. A member registering in both disciplines only pays the
insurance, na!onal compe!tor card and BC Alpine membership costs once,
but receives compe!tor card numbers and ac!ve registra!on
in both FIS Freestyle and FIS Alpine disciplines.
TIMELINES:
Registra!on starts on July 1, 2014 and costs do not increase un!l September 20th, 2014.
WANT AN ALL AREAS PASS? - REGISTER BY August 15:
To qualify for a Canada West All Areas Pass members must be registered with BC Alpine by July 20th, 2014.
PRICING: (standard rate, discount rate rates are available—see below)
$540 Alpine
$520 Ski Cross
$640 Early Dual Discipline
A#er September 20 all costs increase by $115.00
REQUIRED FORMS:
1. FIS Athlete’s Declara!on (New FIS Registrants Only)
2. ACA Registra!on Form
3. FIS Medical Evalua!on Form (requires visi!ng a physician)
4. Na!onal FIS Discount Form (read criteria at bo%om of page)
(Another addi!onal fee of $105 is required for immediate ac!va!on.)
Reference: h#p://bcalpine.com/content/bcalpine/ProgramFees/?Current#feeBreakdown
PRIMARILY RACING IN BC / CANADA?
Price reduc!ons are available for FIS racers who meet
the following criteria:
· will not be a#ending more than one event series
(speed or tech) outside of Canada.
· will not be spending more than 10 days per trip
training / racing in other provinces.
Complete the “Canadian FIS Discount” form to qualify.
Registra!on Ques!ons?
Keven Dubinsky
[email protected]
or call (604) 678-3070
Finance Ques!ons?
Kathy Stahr
[email protected]
or call (604) 678-3071
2014/15 Canadian FIS Discount Form
Members who have applied for a FIS card through BC Alpine and would like to receive the
Canadian FIS Card discounted rate need to send this form to the BC Alpine office.
In order to make sure that coaches are aware of their athletes’ Canadian FIS Card and SAIP
Level status, we require that the FIS Coach / Program Director from your club also sign this
form.
I verify that I would like to have a “Canadian FIS Card”. In signing this I recognize
that my Alpine Canada Sport Accident Insurance Policy will be changed to Class 3
coverage instead of Class 2.
Informa"on on the SAIP levels will be available at:
h#p://alpinecanada.org/saip/
* At the "me of wri"ng this, the new insurance informa"on was not yet available. A Quick Reference is
available at h#p://bit.ly/1yfXzdH
Athlete’s Full Name (Please Print)
FIS Card #
Signature (If under 18, signature of parent/legal guardian)
Date Signed
Club Name
Coach / Program Director Signature
Price Reduc!ons:
Date Signed
Before Sept 20:
A"er Sept 20:
$ 225
$ 200
This form must be signed and sent to BC Alpine. We will then apply a credit to the club for the appropriate amount against the
balance owing from the club for membership costs. Please contact us if you have any ques"ons.
Keven Dubinsky
BC Alpine Ski Associa"on
PH 604-678-3070
offi[email protected]
!
ALPINE CANADA ALPIN
MEMBERSHIP REGISTRATION FORM / FICHE D'INSCRIPTION DES MEMBRES SEASON
A. PERSONAL INFORMATION / RENSEIGNEMENTS PERSONNELS
SAISON
!
SURNAME
NOM
FIRST NAME
PRENOM
SEX
SEXE
DATE OF BIRTH (D/M/Y)
DATE DE NAISSAINCE (J/M/A)
!
MAILING ADDRESS
ADDRESS POSTAL
CITY
VILLE
PROV
PROV
POSTAL CODE
CODE POSTAL
!
HOME PHONE
TÉL DOMICILE
CELL PHONE
TÉL CELLULAIRE
EMAIL
COURRIEL
!
PREFERRED LANGUAGE:
LANGUE DÉSIRÉE:
ENGL
ANGLAIS
FRENCH
FRANCAIS
EMERGENCY CONTACT
CONTACT EN CAS D'URGENCE
MEMBERS HEALTH CARD NUMBER
CARTE D'ASSURANCE MALADIES
RELATION
RELATION
ABORIGINAL ANCESTRY/ACSENDANSE ABORIGÈNE:
STATUS/TREATY/TRAITÉ
PHONE/TÉLÉPHONE:
MÉTIS
INUIT
NON-STATUS
IF UNDER 19 YEARS OF AGE/MOINS DE 19 ANS:
FATHER'S NAME/NOM DU PÈRE
MOTHER'S NAME/NOM DE LA MÈRE
PARENT EMAIL/COURRIEL DU PARENT!
B. PROGRAM INFORMATION / RENSEIGNEMENTS SUR LE PROGRAMME
PTSO/OPS
CLUB NAME/NOM DU CLUB
SELECT ALL BOXES THAT APPLY TO YOUR PROGRAM THIS SEASON
CHOISIS LES CASES QUI SONT APPROPRIÉE À TONS PROGRAMME CETTE ANNÉE
!!!!!!
!
!
!
!
!
!
!
!
!
!
DISCIPLINE
ALPINE/ALPIN
SKI CROSS
PARA-ALPINE/ALPIN
AGE/ÂGE
U6
U8
U10
U12
U14
U16
U18
U21
SR
MA
CLASS/CLASSE
NON-COMP
GENERAL MEMBER/MEMBRE GÉNÉRAL
COACH/ENTRAINEUR
OFFICIAL/OFFICIEL
VOLUNTEER/VOLUNTAIRE
COMPETITIVE/COMPÉTITIF
ENTRY LEVEL/PROG DÉV
RECREATION/RÉCRÉATIONNEL
NATIONAL/NATIONAUX
NATIONAL/NATIONAUX SAIP
MASTERS-WEEKEND PASS
INTERNATIONAL CARDS/CARTES INTERNATIONALES
1ST CARD/CARTES
FIS PROVINCIAL
FIS CANADA
FIS INTERNATIONAL
FIS MASTERS
2nd CARD/CARTES
FIS CANADA
FIS INTERNATIONAL
RETURNING ATHLETES PLEASE LIST YOUR APPLICABLE LICENCE NUMBERS BELOW:
NATIONAL CARD NO:
N.CARTES NATIONAUX:
FIS CARD NO (ALP)
N CARTES FIS (ALP):
FIS CARD NO (SX)
N CARTES FIS (SX)
REVISED JUNE 2014
C. CONSENT / CONSENTEMENT
I HAVE READ AND UNDERSTAND THIS RELEASE OR LIABILITY AND INDEMNIFICATION AGREEMENT ON THE REVERSE PRIOR TO SIGNING IT AND I AM AWARE THAT BY SIGNING THIS RELEASE OF LIABILITY AND
INDEMNIFICATION AGREEMENT I AM WAIVING CERTAIN LEGAL RIGHTS WHICH I OR MY HEIRS, NEXTOF-KIN, EXECUTORS, ADMINISTRATORS AND ASSIGNS MAY HAVE AGAINST THE RELEASEES. IN SIGNING THIS CONSENT/RELEASE I AGREE TO THE
FOLLOWING:
ADMINISTRATORS AND ASSIGNS MAY HAVE AGAINST THE RELEASEES. IN SIGNING THIS CONSENT/RELEASE I AGREE TO THE FOLLOWING:
A) AUTHORIZE ACA/PSO AND/OR CLUB TO USE MY PHOTOGRAPH, IMAGE AND LIKENESS (“MY IMAGE”) IN ALL FORMS AND MANNER INCLUDING BUT NOT LIMITED TO PUBLICATION ON INTERNET WEBSITES, BROADCAST, AND ANY OTHER
PUBLICATIONS AS RELEASED TO OR BY ACA, FOR THE PROMOTION OF SKIING.
B) COLLECTION AND USE OF ALL PERSONAL INFORMATION BY ACA PURSUANT TO ACA’S PRIVACY POLICY, WHICH IS LOCATED ON ACA’S WEBSITE (WWW.ALPINECANADA.ORG)
C) I WISH TO BE NOTIFIED OF ANY SPECIAL EVENTS, OFFERS OR PROMOTION OF ACA AND/OR ITS SPONSORS AND PARTNERS
YES
NO
.
JE DÉCLARE AVOIR LU ET COMPRIS CETTE EXONÉRATION DE RESPONSABILITÉ ET D'INDEMNISATION AU VERSO AVANT DE LA SIGNER. JE COMPRENDS PARFAITEMENT QU'EN SIGNANT LADITE EXONÉRATION DE RESPONSABILITÉ ET D'INDEMNISATION, JE
RENONCE À CERTAINS DROITS RECONNUS PAR LA LOI QUE MES HÉRITIERS OU MOI-MÊME, MES PLUS PROCHES PARENTS, MES EXÉCUTEURS TESTAMENTAIRES, LES ADMINISTRATEURS DE MA SUCCESSION ET MES AYANTS DROIT POURRIONS AVOIR
CONTRE LES RENONCIATAIRES. EN SIGNANT CE CONSENTEMENT/EXONÉRATION, JE CONSENS À:
A) J’AUTHORISE ACA/OSP ET/OU LE CLUB À FAIRE USAGE DE MA PHOTOGRAPHIE, IMAGE ET REPRÉSENTATION (“MON IMAGE”) DANS TOUTES LES FORMES ET DE TOUTES LES FAÇONS POSSIBLE, DONT ET SANS S’Y LIMITER, LA PUBLICATION
SUR LES SITES WEB INTERNET, LA TÉLÉDIFFUSION ET TOUTE AUTRE PUBLICATION ÉMISE À OU PAR ACA POUR LA PROMOTION DU SKI.
B) COLLECTION ET UTILISATION DE TOUS MES RENSEIGNEMENTS PERSONNELS PAR ACA SELON LA POLITIQUE SUR LA VIE PRIVÉE D’ACA QUE L’ON RETROUVE SUR LE SITE WEB D’ACA (WWW.ALPINECANADA.ORG)
C) JE DÉSIRE ÊTRE INFORMÉ DE TOUT ÉVÉNEMENT SPÉCIAL, OFFRE OU PROMOTION D’ACA ET/OU DE SES COMMANDITAIRES ET PARTENAIRES
OUI____ NON____.
RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT!
PARTICIPANT: I AM AWARE THAT SKIING INVOLVES CERTAIN DANGER AND RISKS, INCLUDING, BUT NOT LIMITED TO COLLISION WITH NATURAL AND MAN-MADE OBJECTS AND WITH OTHER SKIERS AND SPECTATORS AND FALLING AT HIGH SPEED
WHILE RACING OR TRAINING AND I FREELY ACCEPT AND FULLY ASSUME ALL SUCH DANGERS AND RISKS AND THE POSSIBILITY OR PERSONAL INJURY, DEATH, PROPERTY DAMAGE OR LOSS RESULTING THERE FROM.
IN CONSIDERATION OF ALPINE CANADA ALPIN (A.C.A.) AND THE CANADIAN SNOWSPORTS ASSOCIATION (THE C.S.A.) ACCEPTING MY APPLICATION FOR REGISTRATION AND PERMITTING ME TO PARTICIPATE IN COMPETITIONS, EVENTS OR TRAINING
AUTHORIZED OR SANCTIONED BY A.C.A. AND THE C.S.A., I HEREBY FOR MYSELF MY HEIRS, NEXT-OF-KIN, EXECUTORS, ADMINISTRATORS AND ASSIGNS, HEREBY AGREE AS FOLLOWS:
1. TO WAIVE ANY AND ALL CLAIMS THAT I MAY HAVE AGAINST A.C.A., THE C.S.A., THE SKI CLUB, ZONE OR DIVISION NAMED IN SECTION ON THE REVERSE. ANY OTHER SKI CLUB OR SKI AREA CONNECTED WITH SUCH COMPETITIONS, EVENTS, TRAINING
AND THEIR DIRECTORS, OFFICERS, COACHES, EMPLOYEES, REPRESENTATIVES, OFFICIALS, AGENTS, VOLUNTEERS AND SPONSORS (ALL OF WHOM ARE HEREINAFTER COLLECTIVELY REFERED TO AS THE RELEASEES).
2. TO RELEASE THE RELEASEES FROM ANY AND ALL LIABILITY FOR ANY LOSS, DAMAGE, INJURY OR EXPENSE THAT I MAY SUFFER OR THAT MY NEXT-OF-KIN MAY SUFFER AS A RESULT OF MY PARTICIPATION IN THE SAID COMPETITIONS, EVENTS
OR TRAINING DUE TO ANY CAUSE, WHATSOEVER, INCLUDING NEGLIGENCE ON THE PART OF THE RELEASEES.
3. TO HOLD HARMLESS AND INDEMNITY THE RELEASEES FROM ANY AND ALL LIABILITY FOR ANY PROPERTY DAMAGE, PERSONAL INJURY OR DEATH TO ANY THIRD PARTY RESULTING FROM MY PARTICIPATION IN THE SAID COMPETITIONS EVENTS OR
TRAINING.
RELEASE OF LIABILITY AND INDEMNIFICATION AGREEMENT (IF COMPETITOR UNDER 19 YEARS OF AGE)
PARENT / GUARDIAN: I HAVE READ AND UNDERSTAND THE RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT SET OUT ABOVE IN CONSIDERATION OF ALPINE CANADA ALPIN (A.C.A.) AND THE CANADIAN SNOWSPORTS ASSOCIATION,
(C.S.A.) ACCEPTING THE APPLICATION FOR REGISTRATION OF:
(HEREAFTER REFERED TO AS "THE COMPETITOR") AND PERMITTING THE COMPETITOR TO PARTICIPATE TO COMPETITONS, EVENTS OR TRAINING AUTHORIZED OR SANCTIONED BY A.C.A. AND THE C.S.A.. I HEREBY FOR MYSELF, MY HEIRS,
EXECUTORS, ADMINISTRATORS AND ASSIGNS AS FOLLOWS:
1. TO WAIVE ANY AND ALL CLAIMS THAT I MAY HAVE AGAINST A.C.A., THE C. S. A., THE SKI CLUB, ZONE OR DIVISION NAMED IN SECTION A ABOVE, ANY OTHER SKI CLUB OR SKI AREA CONNECTED WITH SUCH COMPETITIONS, EVENTS, TRAINING AND
THEIR DIRECTORS, OFFICERS, COACHES, EMPLOYEES, REPRESENTATIVES, OFFICIALS, AGENTS, VOLUNTEERS AND SPONSORS (ALL OF WHOM ARE HEREINAFTER COLLECTIVELY REFERED TO AS THE RELEASEES.)
2. TO RELEASE THE RELEASEES FROM ANY AND ALL LIABILITY FOR ANY LOSS, DAMAGE INJURY OR EXPENSE THAT I MAY SUFFER OR THAT MY NEXT-OF-KIN MAY SUFFER AS A RESULT OF MY OR THE COMPETITOR'S PARTICIPATION IN THE SAID
COMPETITIONS, EVENTS TRAINING DUE TO ANY CAUSE WHATSOEVER INCLUDING ANY NEGLIGENCE ON THE PART OF THE RELEASEES.
3. TO HOLD HARMLESS AND INDEMNITY THE RELEASEES FROM ANY AND ALL LIABILITY FOR ANY PROPERTY, DAMAGE, PERSONAL INJURY OR DEATH SUSTAINED BY THE COMPETITOR OR BY ANY THIRD PART RESULTING FROM THE COMPETITOR'S
PARTICIPATION IN THE SAID COMPETITIONS, EVENTS OR TRAINING.
EXONÉRATION DE RESPONSABILITÉ ET ACCEPTATION DES RISQUES
PARTICIPANT: JE RECONNAIS QUE LE SKI ALPIN COMPORTE CERTAINS DANGERS ET RISQUES Y COMPRIS, SANS Y ÊTRE LIMITÉ, LES COLLISIONS AVEC DES OBJETS NATURELS OU FABRIQUÉS, DES SKIEURS ET DES SPECTATEURS, ET LES CHUTES À
GRANDE VITESSE PENDANT UNE DESCENTE OU L'ENTRAÎNEMENT. J'ACCEPTE ET PRENDS EN CHARGE LIBREMENT ET TOTALEMENT TOUS CES RISQUES ET DANGERS, AINSI QUE LES RISQUES DE BLESSURES PERSONNELLES, DE DÉCÈS, DE
DOMMAGES À LA PROPRIÉTÉ OU DE PERTES QUI POURRAIENT EN DÉCOULER.
DANS LE CAS OÙ ALPINE CANADA ALPIN (A.C.A.) ET L'ASSOCIATION CANADIENNE SPORTS D'HIVER (A.C.S) ACCEPTE MA DEMANDE D'INSCRIPTION ET ME PERMET DE PRENDRE PART À DES COMPÉTITIONS, ACTIVITÉS OU SÉANCES D'ENTRAÎNEMENT
AUTORISÉES OU SANCTIONNÉES PAR L'A.C.A. ET OU L'A.C.S.. JE CONSENS EN MON NOM ET EN CELUI DE MES HÉRITIERS, DE MES PLUS PROCHES PARENTS, DE MES EXÉCUTEURS TESTAMENTAIRES, DES ADMINISTRATEURS DE MA SUCCESSION ET DE
MES AYANTS DROIT, À ME CONFORMER AUX DISPOSITIONS SUIVANTES:
1. JE RENONCE À TOUTE RÉCLAMATION QUE JE POURRAIS AVOIR CONTRE A.C.A., L'A.C.S., LE CLUB DE SKI, ZONE OU DIVISION CITÉ DANS LA SECTION À L'ENDOS, TOUT AUTRE CLUB DE SKI OU TOUTE STATION DE SKI LIÉS À CES COMPÉTITIONS,
ACTIVITÉS, ET SÉANCE D'ENTRAÎNEMENT AINSI QUE LEURS DIRECTEURS, ADMINISTRATEURS, ENTRAÎNEURS, EMPLOYÉS, REPRÉSENTANTS, PORTE-PAROLE, AGENTS, BÉNÉVOLES ET COMMANDITAIRES (ET QUI SONT TOUS DÉSIGNÉS CI- APRÈS
SOUS L'APPELLATION "LES RENONCIATAIRES").
2. J'EXONÈRE LES RENONCIATAIRES DE TOUTE RESPONSABILITÉ POUR TOUTE PERTE, TOUT DOMMAGE, TOUTE BLESSURE OU DÉPENSE QUE MES PLUS PROCHES PARENTS OU MOI-MÊME POURRIONS SUBIR À LA SUITE DE MA PARTICIPATION AUX
DITES COMPÉTITIONS ACTIVITÉS OU SÉANCES D'ENTRAÎNEMENT PEU IMPORTE LA CAUSE, Y COMPRIS LA NÉGLIGENCE DE LA PART DES RENONCIATAIRES.
!3. J'EXONÈRE LES RENONCIATAIRES DE TOUTE RESPONSABILITÉ POUR TOUT DOMMAGE À LA PROPRIÉTÉ, TOUTE BLESSURE PERSONNELLE OU TOUT DÉCÈS D'UNE!
TIERCE PERSONNE, RÉSULTANT DE MA PARTICIPATION AUX DITES COMPÉTITIONS, ACTIVITÉS OU SÉANCES D'ENTRAÎNEMENT.
EXONÉRATION DE RESPONSABILITÉ ET D'INDEMNISATION (MOINS DE 19 ANS)
PARENT / TUTEUR: JE DÉCLARE AVOIR LU ET COMPRIS LA FORMULE D'EXONÉRATION DE RESPONSABILITÉ ET D'ACCEPTATION DES RISQUES DÉCRITE CI-DESSUS DANS LE CAS OÙ ALPINE CANADA ALPIN (A.C.A.) ET L'ASSOCIATION CANADIENNE
SPORTS D'HIVER (A.C.S.) ACCEPTE LA DEMANDE D'INSCRIPTION DE:
(DÉSIGNÉ(E) À L'ENDOS SOUS LE NOM "L'ATHLÈTE") ET LUI PERMET DE PRENDRE PART À DES COMPÉTITIONS, ACTIVITÉS OU SÉANCES D'ENTRAÎNEMENT
AUTORISÉES OU SANCTIONNÉES PAR A.C.A. ET L'A.C.S.. JE CONSENS EN MON NOM ET EN CELUI DE MES HÉRITIERS DE MES PLUS PROCHES PARENTS, DE MESEXÉCUTEURS TESTAMENTAIRES, DES ADMINISTRATEURS DE MA SUCCESSION ET DE
MES AYANTS DROIT, À ME CONFORMER AUX DISPOSITIONS SUIVANTES:
1. JE RENONCE À TOUTE RÉCLAMATION QUE JE POURRAIS AVOIR CONTRE A.C.A., L'A.C.S., LE CLUB DE SKI ZONE OU DIVISION CITÉ DANS LA SECTION À L'ENDOS,
TOUT AUTRE CLUB DE SKI OU TOUTE STATION DE SKI LIÉS À CES COMPÉTITIONS, ACTIVITÉS ET SÉANCES D'ENTRAÎNEMENT AINSI QUE LEURS DIRECTEURS, ADMINISTRATEURS, ENTRAÎNEURS, EMPLOYÉS, REPRÉSENTANTS, PORTE-PAROLE,
AGENTS, BÉNÉVOLES ET COMMANDITAIRES ( ET QUI SONT TOUS DÉSIGNÉS CI- APRÈS SOUS L'APPELLATION "LES RENONCIATAIRES").
2. J'EXONÈRE LES RENONCIATAIRES DE TOUTE RESPONSABILITÉ POUR TOUTE PERTE, TOUT DOMMAGE, TOUTE BLESSURE OU DÉPENSE QUE MES PLUS PROCHES PARENTS OU MOI-MÊME POURRIONS SUBIR À LA SUITE DE MA PARTICIPATION OU
CELLE DU COMPÉTITEUR AUX DITES COMPÉTITIONS, ACTIVITÉS OU SÉANCES D'ENTRAÎNEMENT PEU IMPORTE LA CAUSE, Y COMPRIS LA NÉGLIGENCE DE LA PART DES RENONCIATAIRES.
3. J'EXONÈRE LES RENONCIATAIRES DE TOUTE RESPONSABILITÉ POUR TOUT DOMMAGE À LA PROPRIÉTÉ, TOUTE BLESSURE PERSONNELLE, DÉCÈS DU COMPÉTITEUR OU CELUI D'UNE TIERCE PERSONNE RÉSULTANT DE LA PARTICIPATION DU
COMPÉTITEUR AUX DITES COMPÉTITIONS, ACTIVITÉS OU SÉANCES D'ENTRAÎNEMENT.
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Alpine Canada
MEDICAL EVALUATION
Please attach a photo of the athlete with the completed form
1. ATHLETE PERSONAL INFORMATION
Name ______________________________________________ Date Of Birth (dd/mm/yy):__________________ Sex: M
F
(SURNAME, First Name)
Provincial Health Card Number: _________________________________
Please list any other health insurance coverage you carry:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Club Name: ___________________________________________________________
Provincial Ski Organization: ______________________________________________
2. MEDICAL HISTORY (attach additional pages if necessary)
Family History:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Past Medical / Surgical History (include dates of surgeries and names of Physicians): ________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Immunizations (including DPT/TD, Hep A and B, Flu): ___________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
3. SUMMARY OF PRESENT MEDICAL STATUS (attach additional pages if necessary)
Physical Examination: _____________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Biomechanical Examination (include musculoskeletal exam, joint ROM, alignment): _________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Gender / Reproductive Health: Healthy Male_________ Healthy Female________
Vision: _________________________________________________________________________________________________
(Note: It is recommended that athletes seek to have a Sport Vision Assessment)
4. SUMMARY OF MEDICAL CONCERNS AND ACTION PLAN (attach additional pages if necessary)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
I hereby certify that this athlete is physically able to participate in all aspects of Alpine Ski Racing.
________________________________________________
Physician’s Signature Date
___________________________________________
________________________________________________
Physician’s Name (please print) Telephone
___________________________________________
PLEASE ATTACH ANY ADDITIONAL INFORMATION
** If you get injured during the season ask your coach about the Athlete Injury Survey. If you have a FIS card talk to your
coach about Single Penalty Status.
Alpine Canada Alpin | 1
ATHLETE’S DECLARATION
FOR REGISTRATION WITH THE INTERNATIONAL SKI
FEDERATION (FIS)
I, the undersigned, understanding that my signature to this declaration does not limit the
obligation of the organizer to prepare and maintain competitions courses in accordance with
FIS rules and FIS safety standards then in effect,
Family Name
Discipline: Alpine
First Name
Nordic
Other
YOB
Gender: Male
Nation
Female
make the following declaration:
1. FIS RULES; REGULATIONS AND PROCEDURES
I understand and accept that my participation at any event which is part of the FIS
calendar is subject to my acceptance of all FIS rules applicable in connection with such
event. I therefore agree to be submitted to such rules, regulations and procedures and to the
jurisdiction of the bodies which are in charge of applying them, including but not limited to the
exclusive jurisdiction of the Court of Arbitration for Sport CAS in Lausanne, Switzerland,
where such is provided by FIS rules.
2. ACKNOWLEDGEMENT OF RISKS
I am fully aware and conscious of the potential risks involved in competition skiing activities
and of the risk caused by speed and gravitational forces, be it during training or during the
actual competition. I recognize that there are risks linked with the attempt to achieve
competitive results which requires me to stretch my physical abilities. I also know and accept
that the risks factors include environmental conditions, technical equipment, and atmospheric
influences as well as natural or manmade obstacles. I am further aware that certain
movements or actions cannot always be anticipated or controlled and therefore cannot be
avoided or prevented through safety measures.
Consequently, I know and accept that when I engage in such competitive activities, my
physical integrity and, in extreme cases, even my life may be at risk.
Furthermore, I know and accept that the above mentioned dangers linked with my
participation may threaten third parties within the competition and training area.
I will conduct my own inspection of training and competition courses. I will immediately notify
the jury of any safety concerns I may have. I understand that I am responsible for the choice
of the appropriate equipment and of its condition, for the speed at which I race and for the
selection of my line through the course.
3. PERSONAL LIABILITY
I understand that I may be found personally liable to third parties for damages arising from
bodily injury or property damage they may suffer as a result of an occurrence linked with my
participation in training or competition. I agree that it is not the responsibility of the organizer
to inspect or supervise my equipment.
4. RELEASE
To the extent permitted by the applicable law, I release FIS, my National Association, and the
organizers and their respective members, directors, officers, employees, volunteers,
contractors and agents from any liability for any loss, injury, or damage suffered in relation to
my participation in FIS sanctioned competition or training.
5. DISPUTE RESOLUTION
Without limitation to the jurisdiction of any body of competent jurisdiction in connection with
the application of the FIS Rules, regulations and procedures to which I submit as a
consequence of my participation at events that are published in the FIS calendar (see point 1
above), I agree that any dispute which is not to be adjudicated in application of procedures
provided for by the FIS Rules, regulations and procedures, but which arises between myself
and the FIS and/or the organizer of an event in the FIS calendar, including but not limited to
claims for damages of either party against the other arising out of occurrences (acts or
omissions) linked with my participation to such an event shall be governed by Swiss law and
exclusively settled by arbitration before the Court of Arbitration for Sport (“CAS”) in Lausanne
in accordance with the CAS rules then in effect.
This Declaration be governed and construed according to Swiss law and to the extent
permitted by applicable law shall also be binding on my heirs, successors, beneficiaries, next
of kin or assigns who might pursue any legal action in connection with the same.
I have read and understood the above Athlete's Declaration.
Location
Date
Signature of athlete
For Athletes of minority age (according to national laws):
This is to certify that, as parent/guardian of this participant, I do consent to his/her agreement
to be bound by each of the terms and conditions identified above.
Name (Printed) Parent/Guardian
Date
Relationship
Signature of
Parent/Guardian