Summer Skating Camp 2007 Application
Student Info
Name___________________________________________
DOB_______________________
Address______________________________________________________________________
City________________________________State________________________Zip___________
Telephone_______________________Email_________________________________________
Emergency Contact
Name____________________________Relation______________Phone__________________
Experience Level
[]Evaluate []Beginner []Advanced Beginner
[]Freeskate []Advanced Freeskate []Competitor
USFSA Information
USFSA Level (if available)_________________________________________________________
USFSA Registration #_______________________
If you are not USFSA Registered a $10 annual fee will
be added to this registration cost.
This fee covers your registration for one full year.
Class and Payment Information
[] I July 09 - 12 [] II July
16 - 19 [] III July 23 - 26
[] IV July 30 - Aug 02
[] V Aug 06 - 09 [] VI Aug 13 - 16
[] VII Aug 20 - 23 [] VII Aug 27 - 30
$265 Per Session ($235 if signed up by June 15th)
$150 Minimum Deposit
[] Cash $___________ Rcv'd By___________________________________________________
[] Check $__________ Number_________ Recv'd By__________________________________
[] Credit Card $______ Type_____ #________________ Rcv'd
By________________________
[]$150 Deposit [] Paid in Full
Recv'd By________________________________________
Athletic Waiver and Release of Liability
In consideration of being allowed to participate in any
way in the PALISADES CENTER ICE RINK athletic/sports programs,
related events and activities, the undersigned acknowledges,
appreciates, and agrees that; The risk of injury from the activities
involved
in this program are significant, including the potential
for permanent paralysis and death, while particular rules, equipment and
personal discipline may reduce this risk, the risk of
serious injury does exist and, I KNOWINGLY AND FREELY
ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF
ARISING FROM THE NEGLIGENCE OF THE RELEASEES
or others, and do assume full responsibility for participation;
and, I willingly agree to comply with the stated and customary terms &
conditions for participation, If however, I observe any
unusual significant hazard during my presence or participation, I will
remove
myself from participation and bring such to the attention
of the nearest official immediately; and, I for myself and on behalf of
my children 18 or under, for whom I am signing, my heirs,
assigns, personal representatives and next of kin, HEREBY RELEASE &
HOLD HARMLESS The EklecCo, LLC ("owner"), The Palisades
Center Ice Rink ("Facility"), Ice Management Group. LLC ("Manager"),
their officers, officials, employees and/or agents, other
participants, sponsoring agencies, sponsors, advertisers and if applicable,
owners and
lessors of premises used to conduct the event ("RELEASEES")
WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH,
or loss or damage to person or property, WHETHER ARISING
FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE
during programs at the Facility or while at the Facility
for any other reason, whether on or off the ice. I have read the rules
of
the Palisades Center Ice Rink and will abide by them.
I have explained the rules to my children.
I agree that the staff of the facility may require the
withdrawal from any sessions any skater who violates the rules.
I agree that the Palisades Center Ice Rink is not responsible
for broken, lost or stolen equipment or other expenses incurred while at
the Facility.
Signature of Applicant_________________________________Date___________
FOR PARTICIPANTS OF MINORITY AGE
(UNDER AGE 18 AT TIME OF REGISTRATION)
This is to certify, I as parent or guardian with legal
responsibility for this participant do consent and agree to his/her release
you provided above,
all releases and, or myself, my heirs, assigns,
and next of kin, release and agree to indemnify the RELEASEES from any
and all liabilities
incident to my minor child's involvement or participation
in these programs as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE.
Signature of parent or legal guardian________________________
Date_________