Registration Success

Successful Registration 

A copy of the following registration form was emailed to: [ninja_forms_field id=289]


SKATE COMPANY SKATING CLUB

SPECIAL NEEDS LEARN TO SKATE PROGRAM


 

MAKE CHECKS PAYABLE TO: SKATE COMPANY SKATING CLUB

 

Parent/Guardian’s Information

Name: [ninja_forms_field id=285]
Relation to Skate: [ninja_forms_field id=286]
Home Phone: [ninja_forms_field id=287]
Cell Phone: [ninja_forms_field id=288]
E-Mail: [ninja_forms_field id=289]
Would you like to receive email notifications from our website? [ninja_forms_field id=316]

Skater’s Information

Skater’s Name: [ninja_forms_field id=291]
Address [ninja_forms_field id=292]
City: [ninja_forms_field id=293]
State: [ninja_forms_field id=294]
Zip/Post Code: [ninja_forms_field id=295]
Phone: [ninja_forms_field id=296]
Date of Birth: [ninja_forms_field id=297]
Age: [ninja_forms_field id=298]
Gender: [ninja_forms_field id=299]
Skater’s E-Mail: [ninja_forms_field id=301]

Diagnostic Information

Medical Professional Name [ninja_forms_field id=322]
Medical Professional Phone [ninja_forms_field id=323]
Medical Professional Address [ninja_forms_field id=324]
Medical Professional City [ninja_forms_field id=325]
Medical Professional Zip [ninja_forms_field id=326]
How does the skater communicate? [ninja_forms_field id=327]
Does the skater have seizures? [ninja_forms_field id=328]
If “Yes” how often do they occur? [ninja_forms_field id=329]
On Average, how long do they last? [ninja_forms_field id=330]
Does the skater have a shunt? [ninja_forms_field id=332]
Does the skater have any of the following? [ninja_forms_field id=331]
If Cognitive Impairment [ninja_forms_field id=333]
If Hearing Impairment [ninja_forms_field id=334]

Getting to know your Skater

Name skater prefers to be called [ninja_forms_field id=337]

Signs that the skater may be upset, overwhelmed, or has anxiety [ninja_forms_field id=338]

Sensory Issues [ninja_forms_field id=339]

Special interests that will help reinforce their comfort zone (ex: Thomas the Train, Movies, Character, etc) [ninja_forms_field id=340]

Behavior/OT plans that need to be followed  [ninja_forms_field id=341]

Primary Emergency Contact Information

Emergency Contact Name [ninja_forms_field id=285]
Emergency Contact Relation [ninja_forms_field id=286]
Emergency Contact Phone (Home) [ninja_forms_field id=287]
Emergency Contact Phone (Cell) [ninja_forms_field id=288]
Emergency Contact Email [ninja_forms_field id=289]

Secondary Emergency Contact Information

Emergency Contact Name [ninja_forms_field id=308]
Emergency Contact Relation [ninja_forms_field id=309]
Emergency Contact Phone (Home) [ninja_forms_field id=310]
Emergency Contact Phone (Cell) [ninja_forms_field id=311]
Emergency Contact Email [ninja_forms_field id=312]

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:  [ninja_forms_field id=315]
Late Fee:  [ninja_forms_field id=317]
Total:  [ninja_forms_field id=319]

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