Valley Figure Skating
Club Presents the PRESENTS
Intro
to Club Program
When you are ready for more skating!!
Come Join us for Lots of Fun,
Friendship & Exercise…All Year Round!
All sessions
held at: Tri
County Ice Arena (
Once a
skater passes Basic 5, they are eligible for this program. Skaters can skate 10 times over a 6 months’
time span. Skaters must coordinate their
initial session with a coach or member of the VFSC Board. See our web site for a list of coaches and
board members and our monthly ice calendar: http://www.vfsclub.com/
This is an
easy way to “sample” VFSC instructors and learn about the club. Perfect for first time club
members.
Ice Cost:
$99; Lessons are additional
Skater Name:_____________________________________________________________
Parents Names:___________________________________________________________
Address:_________________________________________________________________
City :_______________________________________State________Zip______________
Home phone:_______________________Cell
phone______________________________
Email
address_____________________________________________________________*Please
fill this in!!!
(a lot of
communication is done by email)
Last Level passed:_______________________________________________
Requested start date:______________________
Do you know any members of our club? If yes, who? _______________________________________
If no, we will pair you with a skater and parent buddy to
answer questions and help you get started!
If you have any questions:
call VFSC President, Mary Bricco 982-9828 or email at marybricco@hotmail.com
Please return this form with your check payable
to “Valley Figure Skating Club” (VFSC) Mail to: Mary Bricco,
Please note this is a one-time offer; skaters may not renew
the Intro to Club program after they have completed their 10 sessions.
The Valley Figure Skating Club, our
professional staff, or any employee of the Tri County Ice Arena or Appleton
Family Ice Center WILL NOT BE HELD
RESPONSIBLE for any accidents or loss of property on or off the ice.
Parent or
Adult Skater’s Signature Date ____________________
Enclosed: Check number______________________________ *** We
will contact you to get you started
AMATEUR ATHLETIC WAIVER AND
RELEASE OF LIABILITY (Required)
Skater’s Name: _________________________________________
(Please Print)
In consideration of
being allowed to participate in the Tri-County Ice Arena/Appleton Family Ice
Center/Valley Figure Skating Club program, related events and activities,
including, but not limited to programs at the Arena and Off-site, the
undersigned acknowledges, appreciates and agrees that:
1.
The risk of
injury from the activities involved in this program is significant, including,
but not limited to, the potential for permanent paralysis and death and while
particular rules, equipment, and personal discipline may reduce this risk, the
risk of serious injury does exist; and,
2.
I KNOWINGLY
AND FREELY ASSUME ALL SUCH RISKS, both known and unknown and assume full
responsibility for my participation; and
3.
I willingly
comply with the stated and customary terms and conditions for participation. If, however, I observe, or in the case of a
minor, the parent(s) or legal guardians(s) 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
4.
I, for myself,
and on behalf of my heirs, assigns, personal representatives and next of kin,
HEREBY RELEASE, WAIVE AND HOLD HARMLESS, TRI-COUNTY RECREATION ASSOCIATION,
TRI-COUNTY ICE ARENA, APPLETON FAMILY ICE CENTER, THE TOWN OF MENASHA,
WINNEBAGO COUNTY, OUTAGAMIE COUNTY AND THE VALLEY FIGURE SKATING CLUB, their
representative administrators, members, directors, agents, coaches, officials,
other participants, sponsors, advertisers, and, if applicable, owners and lessors
of the premises used to conduct the event, including, but not limited to, at
the Arena, in transit to or from the Arena, hereinafter referred to as
“releases”, from any and all liability to each of the undersigned, and any and
all claims, demands, losses or damages on account of INJURY, DISABILITY, OR
DEATH, or loss or damage to property.
5.
I also
understand and accept the fact that by the terms of the ice rental contract
between Tri-County Recreation Association, Appleton Family Ice Center and the
Valley Figure Skating Club, the Tri-County Recreations Association, Inc., the
Tri-County Arena, the Town of Menasha, Winnebago County, Outagamie County, and
the officers, directors, supervisors and employees of the above entities are
not responsible for any property damage or loss suffered by me which occurs in
the locker rooms or any other area wherein property of mine or the skating club
is kept or stored, either permanently or temporarily.
6.
This waiver
and release is understood to supercede and take precedence over any other
agreement or representation, whether written or oral, which contradicts the
terms of this waiver.
I HAVE READ THIS
RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT AND FULLY UNDERSTAND ITS
TERMS. I FURTHER UNDERSTAND THAT I HAVE
GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS FORM, AND HEREBY SIGN IT FREELY,
VOLUNTARILY AND WITHOUT ANY INDUCEMENT.
__________________________________ _____________________________ ____________
Participant’s
Signature Participant’s
PRINTED Name Date
__________________________________ ______________________________
Emergency Contact
Person Emergency
Phone Number
__________________________________________________________________
Participant’s Address
MINOR PARTICIPANT
(Under the age of 18
at the time of registration)
This is to certify
that I, as a parent/guardian with legal responsibility for this participant, do
consent and agree to his/her release as provided above of all Releases from any
and all liabilities to my minor child’s involvement or participation in these
programs as provided above.
__________________________________________ ____________
Parent/Guardian
Signature Date
VALLEY FIGURE SKATING CLUB
SKATER EMERGENCY FORM
This form must be filled out completely and returned with membership packet. Both parent/guardian(s) must sign this emergency form.
DATE: ____________________ GRADE: __________________
SKATER’S NAME: ______________________________ DATE OF BIRTH: __________
ADDRESS: _________________________________________________________________________
Address (City) (zip)
TELEPHONE NUMBER: _____________________ CELL NUMBER: ___________
EMAIL ADDRESS: ___________________________________________________________________
FATHER’S PLACE OF EMPLOYMENT: ________________ PHONE: __________________
MOTHER’S PLACE OF EMPLOYMENT: _______________ PHONE: __________________
IF PARENT CANNOT BE
REACHED, NAME OF RELATIVE OR FRIEND WHO WILL ASSUME TEMPORARY CARE OF YOUR
CHILD:
#1 NAME: _______________________________ RELATIONSHIP: _________________________
ADDRESS: _____________________________________________ PHONE: __________________
#2 NAME: _______________________________ RELATIONSHIP: _________________________
ADDRESS: _____________________________________________ PHONE: __________________
HEATH INFORMATION:
Please list any serious illnesses, severe allergies, or chronic conditions: __________________________
Any medications? ____________________________________________________________________
INSURANCE INFORMATION
MEDICAL INSURANCE: ________________________ INSURANCE #: _____________________
DENTAL INSURANCE: ________________________ INSURANCE #: _____________________
HOSPITAL PREFERENCE: ______________________________________________________________
DOCTOR: _____________________________________ OFFICE PHONE: ____________________
DENTIST: _____________________________________ OFFICE PHONE: ____________________
I/We, the
undersigned, do hereby authorize Valley Figure Skating Club to call an
emergency ambulance in case of accident or acute illness and to arrange for
necessary emergency medical and surgical care in case I/We am not immediately
available. Any qualified physician
called by Valley Figure Skating Club may treat and do whatever is necessary for
the health and well being of my child.
It is
understood that a conscientious effort will be made to notify me/us
(parent/guardian(s)) before such action will be taken. In the event that I/We cannot be contacted,
Valley Figure Skating Club Board Members are hereby authorized to take whatever
action is deemed necessary in their judgment for the health and well being of
my/our child.
I/We will
not hold Valley Figure Skating Club financially responsible for the emergency
care and/or transportation of said child.
______________________________ ________________________________ _________________________
Parent/Guardian Parent/Guardian Date