Canskate Registration Template - Drayton Valley Figure Skating Club

Registration Form 2015/16
Drayton Valley Figure Skating Club
P.O. Box 6813
Drayton Valley, AB
T7A 1S2
Can Skate
Skater’s Name:_____________________________________
AB Health Care #:_______________________
Date of Birth:________________________
(circle one)
Home Phone #_______________________________________
Do you reside in the (check one) Town of DV___________
Brazeau County ___________ Other_____________
Mailing Address:__________________________________________________ Postal Code ______________________
Parent’s Name : Mother _______________________________
Cell #__________________________________
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 a LEVEL and TIME that you are registering in.
Pre-Can Tue/Thur
3 – 4 yrs : 2- ½ hrs/week
Canskate Tue/Thur
Age 5 and up
2 – 1hrs/week
Canskate Sat
Age 5 and up
1 – 1hr/week
$ 182.35
$ 282.35
$ 182.35
Skate Canada Fee
$ 32.65
$ 32.65
$ 32.65
Carnival Costume
$ 40.00
$ 40.00
$ 40.00
Total if Fundraising
$ 255.00
$ 355.00
$ 255.00
Total if NOT
$ 305.00
$ 405.00
$ 305.00
Fundraising Deposit
Cheque Dated
$ 50.00
$ 50.00
$ 50.00
Jan 31/16
Volunteer Dep/Family
Cheque Dated
$ 250.00
$ 250.00
$ 250.00
Mar 01/16
All postdated cheques are to be dated the 1st and 15th of the month ONLY. $25.00 will be charged for any NSF
DVFSC reserves the right to make any changes to the registration form without notice.
*A late fee of $50.00 will apply to any Canskate individual who enrolls in DVFSC after Oct 01, 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 pro-rated 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,
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
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
DVFSC Use Only
Cheque # and Name on Cheque
______________ _______
Date Received ___________________
Volunteers Fee __________
______________ _______
Received By_____________________
Fundraising Fee __________
______________ _______
Refund Date ____________________
Approved By____________________
Skate Canada # __________________________________________________
Tax Receipt # ___________________
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
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