Registration Form 2015/16 Drayton Valley Figure Skating Club P.O. Box 6813 Drayton Valley, AB T7A 1S2 www.dvfigureskatingclub.com Star Skate Skater’s Name:_____________________________________ (last) (first) (middle) AB Health Care #:_______________________ M F Date of Birth:________________________ (circle one) (M/D/Y) Home Phone #_______________________________________ Do you reside in the (check one) Town of DV___________ Brazeau County ___________ Other_____________ Mailing Address:__________________________________________________ Postal Code ______________________ Parent’s Name : Mother _______________________________ Cell #__________________________________ Father________________________________ Cell #__________________________________ Email Address: ____________________________________________________________________________________ Emergency Contact Name & #: Not the same as above :___________________________________________________________________________ Is there any medical information that the club should be aware of? ________________________________________ Any allergies? _____________________________________________________________________________________ Please circle the level that you are registering in. TEST PRE-TEST (Must have passed Can Skate 4) *DVFSC Skate Canada Fee Non-refundable 2 Carnival Costumes Total *After April 13, 2015 F/R Deposit/Skater Cheque Dated Jan 31/16 Music Deposit/Skater Cheque Dated Mar 01/16 Volunteer Deposit/Family Cheque Dated Mar 01/16 Star Skate F/R Star Skate No F/R $ 377.35 $ 457.35 $ 32.65 $ $ 80.00 $ 490.00 *$590.00 $ 80.00 $ 570.00 *$670.00 $80.00 N/A $ 150.00 $ 150.00 $ 250.00 $ 250.00 32.65 Coaching fees for private or group lessons are payable to coaches directly. All post-dated cheques are to be dated the 1st and 15th of the month ONLY. $25.00 will be charged for any NSF cheques. DVFSC reserves the right to make any changes to the registration form without notice. *A late fee of $100.00 applies to any individual who enrolls in DVFSC after April 13, 2015. A skater who leaves the club for any reason, other than medical, will be refunded as follows: 100% of all fees up to 1 week prior to the first day of skating, 100% of the DVFSC amount any time before the first day of skating. All other refunds will be prorated up to the end of October 2015. There will be no refunds after the 1st of November 2015. ***Schedules are subject to change*** Please read and sign back of page Dear Parents, DRAYTON VALLEY FIGURE SKATING CLUB BY LAW #7 – Liability: The Society shall not be responsible for any damages, injury or loss of property to any member of the society, or guest or visitors taken to the society’s premises regardless of the reason or nature of such damage, loss or injury, and further, every member, guest or visitor shall use the society premises and facilities at his or her own risk The Drayton Valley figure skating club unless otherwise stated by you will use the information on these forms for any or all of the following: register the member with Skate Canada, give information to DVFSC executives and to designated volunteers for the purpose of administration of club events and activities, have names published in programs involving the DVFSC, have names &/or pictures published on the clubs bulletin board and in the newspaper or web site. The registration forms are to be kept by the clubs registration chairperson. We are also required (by the freedom of Information and Protection act) to have written consent for the following circumstances regarding your child. So if you could please read over the situations on which you give your consent for: Permission to have picture(s) or video taken of child in the arena by a board member, or other parents. Permission to have picture(s) displayed on the bulletin board, music room or display case. Permission to have child's name appear in the monthly newsletters, bulletins, phoning list and/or on the DV Skate web site. Permission to have child's name appear on the Allergy chart . Permission to have picture(s) taken by the newspaper/media for the purpose of articles pertaining to the Drayton Valley Figure Skating club. I ______________________ give permission for my child ______________________ to be involved in the above situations. __________________________________ Signature ___________________ Date DVFSC Use Only Amount Cash Cheque # and Name on Cheque DVFSC Fee __________ ___________ ______________ _______ Date Received ___________________ Volunteers Fee __________ ___________ ______________ _______ Received By_____________________ Fundraising Fee __________ ___________ ______________ _______ Refund Date ____________________ Music Fee ___________ ______________ _______ Approved By____________________ __________ Siblings_________________________________________________________ Skate Canada # __________________________________________________ Tax Receipt # ___________________ LIABILITY WAIVER AND RELEASE Re: _________________________________________________ ______ (name of volunteer) Re: _________________________________________________ ______ (name of skater) It is understood and agreed, as a condition of volunteering with activities offered by the Drayton Valley Figure Skating Club and Skate Canada, that neither the Club nor Skate Canada shall be liable for any injury, loss or damage suffered by the above note volunteer while travelling to or from or while participating with the ice show or other activities, however caused. It is further agreed that neither the Club nor Skate Canada is responsible for any injury, loss or damage caused by the volunteer while travelling to or from or while participating in the ice show or other activities. The volunteer, who has signed this form, shall indemnify the Club and Skate Canada and hold them harmless from any claims, demands or actions arising from or in respect of such injury, loss or damage. ________________________________ ______________________________ Volunteer Signature Date