Drop-in and Guest Skater Form 2011/12

Skater Details
First name  Last name 
GenderMale/Female Date of birth 
Mailing address
Street 
Town  Province 
Postal code 
Phone numbers
Home  Other 
Email address 
Medical Information
Doctor's Name  Doctor's Phone 
Health No.  Blood Type 
Parents/Guardians Details (if member is 18 years of age or younger)
Names 
Home  Work 
Equipment (please tick to confirm the skater has all the following equipment)
[  ] Neck guard     [  ] Helmet     [  ] Cut resistant gloves     [  ] Knee pads
Visits Maximum of 3 drop-in sessions per season. Each session attended will be recorded below along with the payment received. No limit for Guest Skaters registered with another club.
Date ........Incl. Skates [  ] $ 10Excl. skates [  ] $ 5Received by ........
Date ........Incl. Skates [  ] $ 10Excl. skates [  ] $ 5Received by ........
Date ........Incl. Skates [  ] $ 10Excl. skates [  ] $ 5Received by ........
Declaration

In consideration of your accepting this registration, I hereby, for myself, my heirs, executors, administrators and assigns, waive and release any and all rights and claims for damages I may have against Speed Skating Canada and the Alberta Amateur Speed Skating Association and its member clubs, their agents, officers or members, the Banff/Canmore Speed Skating Club, the Town of Canmore, and the Town of Banff, for any injuries suffered by the member while traveling to or from or participating in skating practices, competitions, or other activities, nor shall they be responsible for any damages or losses caused by the member during the same time. In signing this release I acknowledge the potential for injury.

The Supervisor on duty has my permission to take me or my child for medical attention if they consider it necessary. Registration will be accepted only under such condition.
Signature Date of signature
(signature of adult skater, parent or guardian)