DULUTH AREA SPEEDSKATING CLUB

2010 / 2011 SEASON

Skaters Name____________________________________________________________

Address_________________________________________________________________ City_____________State___________Zip_____________Phone ___________________

Email____________________________________School_________________________

Parent / Guardian_________________________________________________________

Gender M / F     Age______      Birth date_______________   Novice / Advanced

Physician_________________________________________Phone__________________

Dentist___________________________________________Phone__________________

Hospital for emergency_____________________________________________________

Med. Insurance Co___________________________Principal Insured________________

Discipline Policy:  DISRUPTIVE OR INAPPROPRIATE BEHAVIOR IS PROHIBITED

Coaches will have latitude in assigning disciplinary penalties for behavior considered disruptive or inappropriate.  Repeat offenses may result in suspension from the activities.  The duration of the suspension will be determined by the seriousness of the offense.  Fees are not refundable.

Waiver:  All participants in the Duluth Area Speedskating Club’s program are exposed to the possibility of physical injury due to the recreational, athletic, and/or competitive nature of these activities.  Each participant accepts this risk and responsibility as their own by choosing to participate in these activities.  By so participating, each participant waives and releases any and all rights and claims for damages that the participant or his or her heirs or successors may have against Duluth Area Speedskating Club or its personnel, coaches, directors, USS, GMSA, ASU, UMD, City of Duluth arising out of or resulting from the participants voluntary participation in the club sport program.  I understand that long sleeves, gloves, helmets, long pants are required on the ice at all times.

I have read the above waiver and certify my compliance with my signature.

Parent / Guardian Signature__________________________________________________Date__________

Skaters Signature__________________________________________________Date__________

*Starting November 7^th Club Dues $99 / Skater ($250 / family cap)                                            

This covers all indoor ice time at UMD Nov-Dec 9:00-10:00am,

outdoor ice at Chester Bowl, and coaching.

Please make checks to:  Duluth Area Speedskating Club

Mail to:  35 Toledo St

   Duluth, MN  55811

Questions?  Call Paula Rannikko 728-6123