Learn to Skate 2019: Volunteer Skater Registration

Date of Birth
Country
State / Province*
Address
City
Cell Phone # -Please format (610-000-0000)
Email*
Confirm Email*

All event information will come by email. Please list the email address you check most.

Guardian Information

Guardian #1 Name/ Relationship
Guardian #1 Cell Phone (610-000-0000)
Guardian #1 E-Mail
Guardian #2 Name/ Relationship
Guardian #2 E-Mail
Guardian #2 Cell Phone (610-000-0000)
Lives With
Emergency Contact Name/ Relationship
Emergency Contact Phone (610-000-0000)

Medical Information

Medical Conditions
Medication
Allergies
Dietary Restrictions

Liability Waiver

I do hereby assume full responsibility for any and all damages, injuries (including death), or losses that I or my child may sustain or incur, if any, while attending, practicing, participating or witnessing in any club exercise program, sport or physical activity occurring in or about the club premises or at any offsite location. I hereby assume full risk, waive all claims and release and hold B. Reed Henderson High School and the Andrew L. Hicks, Jr. Foundation, its instructors, or partners of said program or event, individually or otherwise, harmless for any and all claims for injuries or damages.

 

I am fully aware and understand that the club does not have on or about the club premises, or employ or contract with any medical services, provisions for ordinary or emergency medical services.

 

In consideration of my child’s participation in and the use of the Club’s facilities, I hereby release and covenant not to sue the Club, its owners, shareholders, directors, officers, employees, representatives, agents, and lessees from any and all claims resulting from any physical injury that may occur to my child while participating in any program or event sponsored by the Warrior Guides or the Andrew L. Hicks, Jr. Foundation.

 

I have read and fully understand the above release/waiver and fully understand that I have given up substantial rights by signing this waiver voluntarily.

Parent or guardians must type name as signature if volunteer is under 18.

Liability Release Signature

Photo/Video Permission

I hereby grant permission to the Andrew L. Hicks, Jr. Foundation to photograph my image and/or that of my minor child and to edit, crop, or retouch such photographs.  I consent to permit those photographs to be used by the Andrew L. Hicks, Jr. Foundation for any purpose, including education and advertisement purposes, and in any medium including print and electronic.

Parent or guardians must type name as signature if volunteer is under 18.

Photo Permission Signature

Please pay the $20 fee at the event,

or mail it to Andrew L. Hicks, Jr. Foundation:

P.O. Box 177, Downingtown, PA 19335.

Additional Comments

Security Code