Welcome to Pines Figure Skating Club

First Name:

Last Name:

Address:

City/State/ZIP:

Email:

Date Of Birth:

Cell Phone:

Home Phone:

USFS#:

Coach:

Are you a U.S. Citizen? Yes No

Are you a Pro/Instructor/Choreographer? Yes No

Primary Activity (Check That Of Which Applies):

Competitive SkaterRecreational SkaterAdult SkaterClub/Office MemberCoach
USFS Official/OfficerOther

PINES FIGURE SKATING CLUB MEMBERSHIP POLICY: If Applicant is under 18 years of age, a Parent or Guardian must sign this application. All Applicants and Members must abide by all Rules and Regulations and will be on a three (3) month probationary period.

If printing application, please place the completed Application, with the Waiver and Release signed, and your check and drop it in the Club mail box at the Pines Ice Arena front office, or mail to: Pines Figure Skating Club Membership, c/o Pines Ice Arena, 12425 Taft Street, Pembroke Pines, FL 33028

There will be a $35.00 charge for Returned Checks.

I hereby apply for Membership in the Pines Figure Skating Club. I understand, If my Application is accepted, I will abide by the Rules and Regulations of the Club and US Figure Skating (USFS).

PLEASE NOTE: FEE IS FOR ANNUAL MEMBERSHIP JULY 1 THROUGH JUNE 30^TH.

Have questions about becoming a member? Please email us at membership@pinesfsc.com

Applicant (if over 19) | Type Name:

Parent/Guardian | Type Name:

Waiver and Release of Liability, Asumption of Risk and Indemnity Agreement

PARENTAL CONSENT AND INDEMNIFICATION AGREEMENT

In consideration of participating in PINES FIGURE SKATING CLUB (Pines FSC) activities, I represent that I understand the nature of figure skating activities (“activity”) and that I am qualified, in good health and in proper physical condition to participate in such “activity”. I acknowledge that if I believe event conditions are unsafe, I will immediately discontinue participation in the “activity”. I fully understand that this “activity” involves risks of serious bodily injury, including permanent disability, paralysis and death, which may be caused by my own actions, or inactions, those of others participating in the “activity”, the conditions in which the “activity” takes place, or the negligence of the “releases” named below; and that there may be other risks either not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, costs, and damages I incur as a result of my participation in the “activity”. I hereby release, discharge, and covenant not to sue the PINES FSC, United States Figure Skating, it’s directors, officers, administrators, sponsors, volunteers, agents, employees, staff, instructors, trainers, other participants and if applicable, owners and lessors of premises on which the “activity” takes place (each considered one of the “Releases” herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the “releases” or otherwise, including negligent rescue operations; and I further agree that if, despite this release, waiver of liability, and assumption of risk, I, or anyone on my behalf, makes a claim against any of the Releases, I will indemnify, save, and hold harmless each of the releases from any loss, liability, damage, or cost which any may incur as the result of such claim. The PINES FSC has the right, but not the obligation, to provide rules, regulations and/or ice monitors for Club Ice. We hereby acknowledge that the PINES FSC shall not be responsible for the supervision of the members at Club Ice. I have read this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT, understand that I have given up substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect.

Participant | Type Name of Participant:

Parental Consent and Indemnification Aggrement

I, the minor’s parent and/or legal guardian, understand the nature of the above referenced activities and the minor’s experience and capabilities and believe the minor to be qualified to participate in such “activity”. I hereby release, discharge, covenant no to sue and AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS each of the Releases from all liability, claims, demands, losses, or damages on the minor’s account caused or alleged to have been caused in whole or in part by the negligence of the Releases or otherwise, including negligent rescue operations, and further agree that if, despite this release, I, the minor, or anyone on the minor’s behalf makes a claims against any of the above Releases, I WILL INDEMNIFY, SAVE AND HOLD HARMLESS each of the Releases from any litigation expenses, attorney fees, loss liability, damage, or cost any Releases may incur as the result of any such claim.

Parent/Gaurdian | Type Name of Parent/Gaurdian:

PHOTO/VIDEO RELEASE FORM:

PHOTO/VIDEO RELEASE FORM

I hereby give permission for images of my child and/or myself, captured during a Club event through video, photo or digital camera, to be used solely for the purposes of the Pines Figure Skating Club promotional material and publications, and I waive any rights of compensation or ownership thereto.

YesNo

Skater | Skater Name:

Skater 2 | Skater 2 Name:

Parent/Guardian | Name of Parent Guardian:

Membership Choice (Select desired membership and click Submit)

$ 93.00 FAMILY MEMBERSHIP

One Skating member (Under 18 years of age) & 1 Non Skating Parent/Guardian