2009 Registration Form - Syracuse University Kool Kats Skating School
Fill in all sections. This form may be copied for additional registrations. Limited enrollment is available. Pre-registration will not be complete until all sections of this form have been completed.
Participant's Name
______________________________________________
Last
First Middle
Age _____ Phone (_____) _____________________
Address ______________________________________________
City ________________________ State _____ Zip ____________
Birth date ___/___/______ Grade next Fall _____
Check the section you are registering for:
Section A (ages 3-8) - Mondays, June 15 - August 3, 5:30 - 6:15pm
Section B (ages 3-8) - Tuesdays, June 16 - August 4, 5:30 - 6:15pm
Section C (ages 9-11) - Tuesdays, June 16 - August 4, 6:15 - 7:00pm
Father's
Name____________________________ Day Phone _______________
Mother's Name ___________________________
Day Phone _______________
Parent's E-mail address
_____________________________________________
In case of emergency notify
______________________Phone _______________
Fees: $80 for each school; $70 for each additional member of same immediate
family.
Assumption of Risk Form: I have adequate medical coverage and give my son/daughter permission to attend the Kool Kats Ice Skating School and we (or I) agree to indemnify Syracuse University and it's employees for any claim which hereafter be presented by our (or my) son/daughter as a result of such injuries. In addition, our (or my) son/daughter understands that he/she will be instructed on the rules and regulations of the Kool Kats Ice Skating School and promises to conform to them.
The health history included is correct, as far as I know, and my (our) child has permission to engage in school activities except as I have described in the medical information. In the event I cannot be reached in an emergency, I hereby give permission to the medical personnel selected by the school director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child attending the Kool Kats Ice Skating School.
Parent/Guardian Signature ______________________________________
Witness ___________________________________ Date _____________
Medical Information: Please note that pre-registration WILL NOT be complete until the medical and insurance information below is completed and the Waiver Form/Release for Medical Treatment found above is signed. Since all the students attending the School are under 18 years of age, it is necessary that our medical staff have the parent's permission to administer treatment in the event of an accident or sudden illness.
| Health | (check all that apply) | __ | Asthma | __ | Allergies | Immunization | DPT Series | _________ | ||
| History | __ | Ear Infections | __ | Bee Stings | __ | Migraines | History | Booster | _______ | |
| __ | Hay Fever | __ | Convulsions | __ | Food Allergy | (fill in dates) | Measles (live) | _______ | ||
| __ | Diabetes | __ | Penicillin | __ | Heart Murmur | Rubella | _______ | |||
| __ | Other Drugs | __ | Behavior Disorder | Tetanus | _________ | |||||
| __ | Other (explain) | __________________ | Tuberculin Test | _________ |
Please explain below if
the player: 1) requires taping or splinting for participation; 2) requires a
physician's clearance to participate due to a chronic illness, a serious illness
within the past six months, surgery or a serious injury. __________________________
________________________________________________________________________________________
Participants with the following conditions must provide written physician's
clearance before attending this school. Please return an official letter of
physician's clearance with this form for each item circled "yes".
| yes no | Fracture in the last 6 months | yes no | Spinal Injury |
| yes no | Surgery in the past one year | yes no | Diabetes |
| yes no | Heart Condition (including murmurs) | yes no | Hemophilia |
| yes no | Illness in the last month | yes no | Seizure Disorder |
| yes no | Loss of Organ |
List any medications that the participant is currently taking (be specific)________________________________
Insurance Coverage: For accidental injury; required by all participants. Family health insurance is adequate in most cases.
I have the required insurance. (complete all lines)
| Insurance Company | ____________________ | Policy holder's Name | _____________________ | ||||
| Relation to participant | ____________________ | Policy holder's S.S. # | _____________________ | ||||
| Policy / Group # | ____________________ | Is pre-approval required? | ____________ | ||||
| If yes, Insurance Co. # | _____________________ | ||||||
Payment: $80
for school,
$70 for each additional member of same immediate family.
Deadline for Registering: June 12, 2009.
| Amount: $____________ | Circle | Check | Cash | Master Card | Visa |
| Credit Card # __________________________________ | Exp Date | ________ | |||
| Checks payable to: Syracuse University | Send to: | Tennity Ice Skating Pavilion | |||
| 511 Skytop Rd | |||||
| Phone:315-443-8416; Fax 315-443-4632 | Syracuse, NY 13244 | ||||