Devo Enrollment

JUNEAU SKI CLUB DEVO Enrollment Form 2009/2010 Athlete Information Last Name: Sex:

First Name: Date of Birth:

School:

Age: Grade:

Mailing Address: Residence Address: Home Phone:

Work Phone:

Cell Phone:

E-mail: Parent(s) or Guardian(s) Please check here if USSA fees have been paid for 2009/2010 USSA Alpine Competitor License #: Devo Team 1day, Includes 3, 3day camps

Youth Ski League License # $

500.00

$

30.00

______ Juneau Ski Team Membership (one per family)

PRIOR TO PARTICIPATION IN DRY LAND FITNESS TRAINING A DEPOSIT OF $200.OO MUST BE PAID AND THE MEDICAL RELEASE TURNED IN.

Total Paid:

Total Due:

Check Number: Individual payment plans are available and must be set up in advance with JSC Treasurer. Payments can be sent to:

Juneau Ski Club P.O. Box 32358 Juneau, Alaska 99803

Juneau Ski Club DEVO Release Form 2009/2010 PLEASE READ AND COMPLETE THIS FORM Statement of Risk: I, understand that alpine skiing carries significant risk of personal injury. I know there are natural and man-made obstacle or hazards, surface and environmental conditions and risks which in combination with a racer’s actions could cause severe or occasionally fatal injury. In participating in the Juneau Ski Club programs and skiing at Eaglecrest, such dangers are recognized and accepted whether they are marked or unmarked. I hereby release and hold harmless the Juneau Ski Club it’s coaches, race officials, USSA, USSA Alaska Division and any person connected with the above program during participation in any events, use of ski Club facilities or equipment, team travel or any events associated with the Juneau Ski Club Programs. ENROLLMENT OF NAMED ATHLETE By signing below, I hereby agree to enroll the athlete named above with the Juneau Ski Club and agree to pay all membership dues and program fees for named athlete by December 1, 2009. Individual payment plans must be arranged with the Treasurer. Code of Conduct Parent’s Acknowledgement: I hereby certify that as a parent or guardian of the named participation athlete that I acknowledge and agree to abide and have the named athlete abide, by the code of conduct as written in the Juneau Ski Club Handbook. Athlete Acknowledgement: I acknowledge that I have read the code of Conduct as written in the Juneau Ski Club Handbook and I agree to all the rules and regulations. Release Authorization for Medical Attention I hereby grant permission for a doctor to perform any diagnostic procedure, anesthetic, operation, or curative remedial procedure they deem necessary or advisable for the care and treatment of the above named skier. Please Read and Understand above BEFORE signing. Signature of athlete: Date: Signature of parent or guardian:

Date:

MEDICAL EMERGENCY CONSENT FORM If your child needs emergency medical care and you aren’t available to give formal consent to medical authorities, care may be unnecessarily delayed. To protect your child, leave a completed EMERGENCY CONSENT FORM. Parents or Guardian’s Name: I/we hereby authorize Juneau Ski Club to give consent for all medical and pr surgical treatment that may be required for our child during our absence. CHILD’S NAME: CHRONIC ILLNESS: CURRENT MEDICATION: TETANUS IMMUNIZATION: (date) ALLERGIES: Parent’s or Guardian’s Name: Home Address of Parent/Guardian: Home Phone:

Cell Phone:

Employer:

Phone:

Health Insurance Co.: S.S. # Nearest Relative: Signature of Parent/Guardian

mcm# Group# Phone Date