| Skater Details | |||
| First name | Last name | ||
| Gender | Male / Female | Date of birth | |
| Citizenship | SSC number | ||
| (Required for SSC registration) | |||
| Mailing address | |||
| Street | |||
| Town | Province | ||
| Postal code | |||
| Phone numbers | |||
| Home | Work | ||
| Cell | Other | ||
| Email address 1 | |||
| Email address 2 | |||
| (Required for SSC registration and to receive BCSSC and SSC correspondence) | |||
| Parents/Guardians Details | |||
| (if member is 18 years of age or younger) | |||
| Names | |||
| Home | Work | ||
| Cell | Other | ||
| Emergency Contact Details | |||
| (other than parents/guardians) | |||
| Names | |||
| Home | Work | ||
| Cell | Other | ||
| Medical Information | |||
| (Information is confidential and released only to coaches and medical professionals) | |||
| Doctor's Name | Doctor's Phone | ||
| Health No. | Blood Type | ||
| Asthma Sufferer | Yes / No | Contact Lenses | Yes / No |
| Allergies | |||
| Medications | |||
| Chronic conditions | |||
| (includes repetitive strain injuries) | |||
| Concussions (date) | |||
| Other injuries (type/date) | |||
| Membership | |||
| (please tick one) | |||
| Competitive | [ ] $ 100 | Recreational | [ ] $ 60 |
| Coach/Official | [ ] $ 20 | Volunteer | [ ] $ 0 |
| Program - full season | |||
| (please tick one) | |||
| Once per week | [ ] $ 180 | Twice per week | [ ] $ 300 |
| 3 times per week | [ ] $ 390 | Drop-in | [ ] $ 10 each session |
| Program - half season | |||
| (please tick one, for those joining after 31st December) | |||
| Once per week | [ ] $ 90 | Twice per week | [ ] $ 150 |
| 3 times per week | [ ] $ 195 | Drop-in | [ ] $ 10 each session |
| Attendance | |||
| (please tick the times you expect to attend to help the club plan sessions) | |||
| Beginners SUN | [ ] 5:45 to 6:45 PM | Inter/Advanced SUN | [ ] 7:00 to 8:00 PM |
| Beginners WED | [ ] 5:30 to 6:30 PM | Inter/Advanced WED | [ ] 6:30 to 7:30 PM |
| Beginners FRI | [ ] 4:15 to 5:15 PM | Inter/Advanced FRI | [ ] 4:15 to 5:15 PM |
| Skate Rental | |||
| (rental form must also be completed for rented skates) | |||
| Deposit paid | [ ] $ 100 | Deposit cheque no. | |
| Full season | |||
| (please tick one) | |||
| Van Horne Skates | [ ] $ 100 | Bont Skates | [ ] $ 75 |
| Other Skates | [ ] $ 50 | Own Skates | [ ] no charge |
| Half season | |||
| (please tick one, for those joining after 31st December) | |||
| Van Horne Skates | [ ] $ 100 | Bont Skates | [ ] $ 75 |
| Other Skates | [ ] $ 50 | Own Skates | [ ] no charge |
| Declaration | |||
| Total fees paid | $ | Received by | |
|
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 and the Town of Canmore, 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.
|
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| Signature | Date of signature | ||
| (signature of adult skater, parent or guardian) | |||