| Registration Form: Skater Name:____________________________________________________________________ Parent/Guardian Name:___________________________________________________________ Address:________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Phone #:________________________________________________________________________ Date of Birth:___________________________________________________________________ Health Card #:__________________________________________________________________ Male:_______________________________Female:_____________________________________ Medical Conditions if any:_________________________________________________________ ________________________________________________________________________________ Skate Canada #__________________________________________________________________ Coaches Name_________________________________Phone #:___________________________ HomeClub:_____________________________________________________________________ Home Club #___________________________________________________________________ Guest Skating: $20.00 for 1 On-Ice Session $25.00 for 1 On-Ice and 1 Off -Ice Session $35.00 for 2 On-Ice and 1 off-Ice Session For further pricing on special membership requests call Tracy at (905) 434-7895 Please enclose a cheque which is 50% or more of the membership fee. Balance payable on or before June 2, 2003. BOTH CHEQUES MUST ACCOMPANY FORM. |
| Application Form High Competitive 5 days for 4 weeks = $380.00 + GST Low Competitive 4 days for 4 weeks = $250.00 + GST Low Test 2 days for 4 weeks =$125.00 + GST 2 days for 4 weeks without Patch = $105.00 + GST Please find enclosed a cheque payable to DURHAM REGION SKATING ACADEMY in the amount of$_________________, which is 50% or more of the membership fee. Balance payable on or before June 2, 2003. Both cheques must accompany form. The applicant agres that the Durham Region Skating Academy and/or its proprietors and coaches will not be held responsible for any accident or loss, however caused, and also agrees to release the aforementioned form all claims and or damages, which may arise from any such accident or loss. Signature of Parent or Guardian: _____________________________________________________________ Sate of Application:_____________________________________________ Please send Application form/Registration Form along with Payment to: DRSA c/o Tracy Tutton 5 Found Court Courtice, Ontario L1E 2V2 |