Registration Success

Successful Registration 

A copy of the following registration form was emailed to:


SKATE COMPANY SKATING CLUB

SPECIAL NEEDS LEARN TO SKATE PROGRAM


 

MAKE CHECKS PAYABLE TO: SKATE COMPANY SKATING CLUB

 

Parent/Guardian’s Information

Name:
Relation to Skate:
Home Phone:
Cell Phone:
E-Mail:
Would you like to receive email notifications from our website?

Skater’s Information

Skater’s Name:
Address
City:
State:
Zip/Post Code:
Phone:
Date of Birth:
Age:
Gender:
Skater’s E-Mail:

Diagnostic Information

Medical Professional Name
Medical Professional Phone
Medical Professional Address
Medical Professional City
Medical Professional Zip
How does the skater communicate?
Does the skater have seizures?
If “Yes” how often do they occur?
On Average, how long do they last?
Does the skater have a shunt?
Does the skater have any of the following?
If Cognitive Impairment
If Hearing Impairment

Getting to know your Skater

Name skater prefers to be called

Signs that the skater may be upset, overwhelmed, or has anxiety

Sensory Issues

Special interests that will help reinforce their comfort zone (ex: Thomas the Train, Movies, Character, etc)

Behavior/OT plans that need to be followed  

Primary Emergency Contact Information

Emergency Contact Name
Emergency Contact Relation
Emergency Contact Phone (Home)
Emergency Contact Phone (Cell)
Emergency Contact Email

Secondary Emergency Contact Information

Emergency Contact Name
Emergency Contact Relation
Emergency Contact Phone (Home)
Emergency Contact Phone (Cell)
Emergency Contact Email

Representations, Acknowledgements, and Agreements

 1. I hereby represent and certify that the age of the registrant listed is correct and acknowledge and agree that the registrant is physically fit to engage in both structured and unstructured activities at the Lincoln Park Community Center.
 2. I acknowledge the inherent risk of serious injury or even death associated with ice skating, and ice hockey activities and I hereby release, discharge, and agree to indemnify and hold harmless the Skate Company Skating Club, Lincoln Park Community Center, its owners, managers, affiliates, and employees from any and all claims by or on behalf of the registrant arising from the registrant’s participation in ice skating and ice hockey activities at Lincoln Park Community Center.
 3. I hereby represent and certify that the registrant has adequate health insurance to cover any and all injuries occurring as a result of participation in ice skating, and ice hockey activities at the Lincoln Park Community Center and as the parent or legal guardian of the participant, I hereby consent to any and all emergency medical care for participant and agree to pay for same.

Totals

Class Fee:  
Late Fee:  
Total:  

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