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| Name: |
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Date of Birth: |
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| Address: |
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City: |
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State: |
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Code: |
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Email: |
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Phone: |
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| Emergency
Contact: |
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Emergency Phone: |
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Clinics |
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| Session
# |
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Sport |
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Day |
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Session 1 (Sept.) |
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¦ Monday |
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Session 2 (Nov.) |
¦ Learn
To Skate |
¦ Tuesday |
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Session 3 (Jan.) |
¦ Multi
- Sport |
¦ Wednesday |
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Session 4 (Feb.) |
¦ Multi
- Sport |
¦ Thursday |
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Session 5 (April) |
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¦ Friday |
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Other__________ |
¦ Other__________ |
¦ Saturday |
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Prices: |
Learn To Skate - $119 |
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Multi-Sport - $79 |
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Camps |
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# |
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Sport |
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Christmas Vacation |
¦ Multi
- Sport |
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February Vacation |
¦ Peewee
Multi - Sport |
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April Vacation |
¦ In-Line |
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Summer Session 1 |
¦ Peewee
In-Line (3 day) |
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Summer Session 2 |
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Summer Session 3 |
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Prices: |
Inline and Multisport - $175 |
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Peewee Inline and Multisport - $79 |
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| Participant
Release of Liability (Please read before signing below) |
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| The
risk of injury from the activities involved in this program is potentially
significant, including the potential for permanent paralysis and death, and
while |
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| particular
rules, equipment, and personal discipline may reduce the risk, I knowingly
and freely assume all such risks, both known and unknown, even if arising |
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| from
the negligence of the releasees or others, and assume full responsibility for
my participation; I willingly agree to comply with the stated and customary |
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| terms
and conditions for participation. If
however, I observe any unusual significant hazard during my presence or
participation, I will remove myself from |
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| participation
and bring such to the attention of the nearest official immediately; and, I,
for myself and on behalf of my heirs, assigns, personal representatives |
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| and
next of kin, hereby release, indemnify, and hold harmless ZRink, their
officers, officials, agents and/or employees, other participants, sponsoring
agencies, |
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| sponsors,
advertisers, and, if applicable, owners and lessors of premises used to
conduct the event, with respect to any and all injury, disability, death, or
loss |
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| or
damage to person or property, to the fullest extent permitted by law. If under 18 at time of
registration, I, as parent/guardian with legal |
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| responsibility
for this participant, do consent and agree to his/her release as provided
above. |
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| Participant/Guardian
Signature________________________Particpant/Guardian
Name_________________________ |
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| Medical
Condition(s)________________________Date__________ |
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| Office
Use Only: Total
Amount Due__________Total Payment__________Rec'd by__________ |
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| Payment
Method_________Check #__________Payment Date__________ |
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