DFSC 2011-2012 REGISTRATION

This is a pay by check form. It is submitted elecectronically and matched to your payment by check.

* Skater's Full Name

USFSA Number: (Optional; DFSC can access database)

* Address

* City, State, Zip

* Date of Birth

* Email Address

* Highest MIF Test Passed
(Enter BEG if skater has not tested)

* Highest Freestyle Test Passed
(Enter BEG if skater has not tested)

* Coach

* Parent(s)/Guardian(s)

* Home Phone Number

* Cell Phone Number

* Emergency Contact (Other than Parent/Guardian)

* Emergency Contact Phone Number

* Emergency Medical Facility

* Physician

* Insurance Provider

* Home Club (if other than Duluth)

Type of Membership

A PDF of the different membership types and guidleines is available here.

Select Only One

Home Club Individual

$160 July 1, 2011 to June 30, 2012

$105 Feb 1, 2012 to June 30, 2012

Home Club Family - Family membership consists of one parent/legal guardian and up to 3 children less than 19 years old residing at the same address. Add $10 for each member over and above four.

$185 July 1, 2011 to June 30, 2012

$125 Feb 1, 2012 to June 30, 2012

Skater 2 Full Name

USFSA #

Date of Birth

Coach

Highest MIF

Highest Free

Skater 3 Full Name

USFSA #

Date of Birth

Coach

Highest MIF

Highest Free

Skater 4 Full Name

USFSA #

Date of Birth

Coach

Highest MIF

Highest Free

Additional Skater 1

$10

Addt'l Skater Full Name

USFSA #

Date of Birth

Coach

Highest MIF

Highest Free

Additional Skater 2

$10

Addt'l Skater Full Name

USFSA #

Date of Birth

Coach

Highest MIF

Highest Free

Home Club NON-CONTRACTING

$110

Associate Individual*

$115 July 1, 2011 to June 30, 2012

$90 Feb 1, 2012 to June 30, 2012

Associate Family* See family definition above. Add $10 for each member over and above four. Make your selection and then complete the skaters information in the Home Club family member section above.

$150 July 1, 2011 to June 30, 2012

$115 Feb 1, 2012 to June 30, 2012

$10 Additional Associate Family Member 1 )

$10 Additional Associate Family Member 2

Collegiate** Individual must be a student at an accredited secondary or post-Secondary institution and provide proof of enrollment at timeofegistration.

$225 Membership valid for 4 years from date of registration.

Quarterly $50 (Check one below) Individual must have completed at least two DFSC Learn to Skate sessions to participate in Jr Club sessions.

Q1 July 1, 2011 to Sept 30, 2011

Q2 Oct 1, 2011 to Dec 31, 2011

Q3 Jan 1, 2012 to Mar 31, 2012

Q4 Apr 1, 2012 to June 30, 2012

* Associate member must be home club member of another USFSA sanctioned skating club or individual member of USFSA.

** Collegiate member may only contract ice on weekends and during summer (Jun/Jul/Aug). Monitor duties apply excluding summer months.

Emergency Medical Treatment Permission/Waiver

I hereby authorize the Duluth Figure Skating Club (DFSC), through its representatives, to obtain emergency medical treatment for the skater named above. Further, I request that the skater named above be allowed to participate in DFSC activities, both on and off the ice, and I release the DFSC, its members and its coaches from any responsibility for injuries to the above named skater during DFSC activities. I understand there is a risk of serious injury from these activities.

* Check this box to indicate that you agree with the above Emergency Medical Treatment Permission/Waiver

I agree

Website Permissions

I hereby authorize the Duluth Figure Skating Club (DFSC) to display skating related photographs of the skater named above and to provide skating related information about the skater named above on the DFSC website.

* Check this box to indicate your consent of the Website Permissions.

I agree

I disagree

Payment Information

DFSC must receive your payment within 5 business days in order to register your skater(s) with the USFSA. If not received within that time frame, you will need to register your skater(s) again.

Pleasse make you check payable to DFSC and mail it to:

Treasurer
4386 Normanna Road
Duluth, MN 55803

* Indicates Response Required