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Please Print Clearly
First Member: ____________________________________________________________________________________________
Address: ____________________________________________________________________________________
Telephone Number:( )_____________________Other Number ( )_____________________________
Email Address:________________________________ Birth Date:_____/_____/______
USFSA Number:_____________________Highest Test USFSA Passed:_____________________________
Are you currently enrolled in Learn-to-Skate? Y or N If yes current level:_______________________________ Name(s) of additional family members/skaters becoming JFSC members (including parents):
Name________________________________________________________Birth Date: _____/_____/_______
Name________________________________________________________Birth Date: _____/_____/_______
Name________________________________________________________Birth Date: _____/_____/_______
Membership Category for which you are applying (Circle one):
Junior Member (under 18 years of age) with 1 Parent: $70; Each additional family member $22 Senior Member: $70 Associate Member: $45; Each additional family member $20 JFSC Registered Coach: $40; Associate Coach: $30
Current Home Club (for Associate):______________________________________________________________
Amount due: $______________________
Applicant’s Signature:___________________________________________________Date:___________________
Parents Signature (if Applicant is under 18):
_____________________________________________________________________Date:___________________
Hold Harmless Statement
Skaters Name(s):_______________________________________________________Date:___________________
Address:_____________________________________________________________________________________
Telephone:________________________________Emergency Number:___________________________________
I acknowledge that there are certain risks of physical injury to participate in the programs. That I agree to assume full risk of any such injuries, danages or loss which I or my child might sustain as a result of participation in any activities during the course of The Janesville Figure Skating Club activities. I fully release, discharge and hold harmless The Janesville Figure Skating Club, Janesville Ice Arena and their officers, agents and employees from any and all claims from injuries, damages or loss due to my or my child’s participation in, arising out of, or in any way associated with these activities. I have read, understand and agree to the statement above.
Signature (Parent or guardian if under 18):_______________________________________________________ Club Website can be found at: www.janesvillefsc.org Send Membership Applications to: Janesville Ice Skating Center, 821 Beloit Ave., Janesville, WI 53545 |