2015 - 2016 Hickory Hill Figure Skating Club Membership Form
Membership year 7/1/15 - 6/30/16
Contact E-mail Address
*
Contact Phone Number
*
Mailing Address:
Street and Number
*
City
*
State
*
Zip Code
*
Primary Member (
must be over 18 years of age; minors need to have a parent/guardian as primary member)
:
First Name
*
MI
Last Name
*
Gender
*
Please Select
Female
Male
Date of Birth
*
-
Month
-
Day
Year
Date
USFSA #
*
Primary Skating Activity (Choose one) :
*
Please Select
Competitive Skater
Recreational Skater
Coach
Parent/Guardian
USFS Official
Club Officer
Officer
Other Skating Activities (Check all that apply) :
Competitive Skater
Recreational Skater
Adult Skater
Synchro Skater
Coach
Parent/Guardian
USFS Official
Club Officer
Other
US Citizen?
Please Select
Yes
No
Second Member Information
:
First Name
MI
Last Name
Gender
Please Select
Female
Male
Date of Birth
-
Month
-
Day
Year
Date
USFSA #
Primary Activity Skating Activity (Check one) ::
Please Select
Competitive Skater
Recreational Skater
Coach
Parent Guardian
USFS Official
Club Officer
Other
Other Skating Activities (Check all that apply) :
Competitive Skater
Recreational Skater
Coach
Parent/Guardian
USFS Official
Club Officer
Synchro Skater
Other
US Citizen?
Please Select
Yes
No
To add another family member, go to the end of this form.
Volunteer!!! From time to time, we need your assistance with club sessions, hospitality, testing and competitions. would you be willing to help out?
Yes, I"d like to help!
true
Payment Information - choose one category of membership:
prev
next
( X )
Individual Member
$
80.00
Family of 2 Members
$
120.00
Family of 3 or More Members
$
140.00
Coach
$
65.00
Introductory Membership (new member)
$
25.00
Introductory Family of 2 Membership
$
45.00
Individual - Associate (enter home club below)
$
55.00
HHFSC Judge
$
52.00
Total
$
0.00
Home Club if HHFSC Associate Member
www.hhfsc.org
Membership Agreement:
I agree by clicking "Submit Form" below to purchase the membership as detailed and to abide by the Hickory Hill FSC Code of Conduct as posted on the Club website (www.hhfsc.org). Membership may be terminated if Hickory Hill FSC rules of conduct are not followed. The Club may refuse this contract if there are any outstanding balances of dues. Skaters whose membership and ice time payments are not maintained will not be allowed to use Club ice or retain permission to test, compete or exhibit until those accounts are cleared. I hereby authorize the Hickory Hill FSC to photograph the member(s) named above for the sole purpose of using such photographs for Club business such as the website, social media, brochures, media coverage and other such purposes as may be deemed appropriate to benefit the Club and its membership, excluding commercial endeavors. I hereby release discharge and covenant not to sue the US Figure Skating Association, the Hickory Hill Figure Skating Club, their respective administrators, directors, agents, officers, volunteers, employees and any sponsors and advertisers of any USFSA-sanctioned event in which I participate (each considered one of the Releasees 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 Releasees. This release, waiver of liability and express assumptions of risk agreement does not apply to any liability, claims, demands, losses, or damage arising out of the gross negligence of, or intentional, willful or wanton misconduct of Releasees. If I, on my and/or my minor child"s behalf, makes a claim, I agree I will indemnify, defend, save, and hold harmless each of the Releasees from any loss, liability, damage, or cost which any may incur as the result of such claim. I acknowledge that I have read this release, waiver of liability and express assumptions of risk agreement, and fully understand it.
Third Member Information
:
First Name
MI
Last Name
Gender
Please Select
Female
Male
Date of Birth
-
Month
-
Day
Year
Date
USFSA #
Primary Activity Skating Activity (Check one) ::
Please Select
Competitive Skater
Recreational Skater
Coach
Parent Guardian
USFS Official
Club Officer
Other
Other Skating Activities (Check all that apply) :
Competitive Skater
Recreational Skater
Coach
Parent/Guardian
USFS Official
Club Officer
Synchro Skater
Other
US Citizen?
Please Select
Yes
No
Save
Proceed to Checkout
Should be Empty: