Creve Coeur Figure Skating Club Updated 06/01/2015 2015-2016 Membership Application Form For the year June 1, 2015 through June 30, 2016 Home Club Membership Associate Membership All Home Club memberships include one (1) Skating magazine and USFS membership. With the Family Membership, one member would be designated as receiving the Skating magazine and all would be members of the USFS. First Name MI Street Address Last Name Gender City Work Phone Date of Birth (MM/DD/YYYY) State Home Phone Cell Phone Email Address USFS# (if any) Zip Code U.S. Citizen (Y/N) Home Club (If joining as an associate member) Members under 18 years of age are Junior Members. Each HOME CLUB Junior Member will have one parent/guardian as a member who should complete the following: Parent/Guardian Name Work Phone Address (if different than above) Cell Phone USFS# (if any) Date of Birth (MM/DD/YYYY Gender U.S. Citizen (Y/N) Membership Fees Membership Make check payable to: CCFSC (Please Circle Membership Choice ) Family Membership (1)Skater under 18 years old Plus (Each Additional Family Member/Skater under 18) or Senior Member 18 years or older Associate Member (Home Club Member of Another Club) Professional Member Collegiate Membership (4 year membership) Supporting Member USFS Introductory Membership (First Time USFS Member) Introductory Family Membership - (1) Skater under 18 years old Introductory Senior Membership - 18 years or older $115.00 $45.00 $70.00 $70.00 $70.00 $130.00 $110.00 – Mail to: Ley Fatzinger 1668 Fontana Dr St. Louis, MO 63146 [email protected] Membership Fee Total: IF YOU ARE A SKATER AND/OR PLAN TO BE ON $60.00 THE ICE AT ANY TIME, AN EMERGENCY MEDICAL $45.00 RELEASE/WAIVER MUST BE COMPLETED AND TURNED IN AT THE CREVE COEUR RINK. ________ Total Amount Enclosed: ________ –  Yes, I wish to receive email from CCFSC regarding events, changes to ice schedule, and reminder notices. I would be interested in volunteering for:     Hospitality Fund Raising Ice Monitor Competitions Other:_______________ Acceptance of membership in the Creve Coeur Figure Skating Club subjects the member to all rules and regulations of the club and requires that each member support club activities. I hereby waive any right to claim damages against the club, its officers, directors and members, and release any and all of them from any liability that may arise out of my membership therein. I also hereby give my consent for my skater or myself to be photographed during CCFSC functions and allow posting of photographs in CCFSC publications, including the CCFSC website, newsletter and ice arena bulletin board and release the Creve Coeur Figure Skating Club from any liability for their use. _________________________________________________________ Member’s Signature Date ________________________________________________________ Parent/Guardian Signature (if member is under 18) Date