HERITAGE SKATING ACADEMY (HSA)
July 1, 2014 – June 30, 2015 Membership and Fees
Instructions: Complete all fields. Please print. Use an additional form if needed for additional family members.
Junior Member (Ages 1-17; A parent/guardian must also be a member. Also complete “Parent/Guardian”section*)
Name: _________________________________________ Sex: Male ___ Female ___ USFS#: _________________
Address: _______________________________________ Age: ____ Date of Birth: ___________________________
City: ________________________________ State: _____ Zip: ______________ U.S. Citizen? Yes ____ No ____
Phone: ______________________________ Email Address: ______________________________________________
Adult Member (Ages 18 or Older) or Parent/Guardian Member
Name: _________________________________________ Sex: Male ___ Female ___ USFS#: _________________
Address: _______________________________________ Age: ____ Date of Birth: ___________________________
City: ________________________________ State: _____ Zip: ______________ U.S. Citizen? Yes ____ No ____
Phone: ______________________________ Email Address: ______________________________________________
Skating Level: Basic: ______________ Freestyle: ________________ Dance: _____________ Pairs: _____________
Have you ever been a member Not in “good standing?” Yes ______ No ______ If Yes, please attach details.
Primary Coach: _______________________ Coach Phone: _______________ Coach Email: ____________________
Home Club (If Purchasing a 2nd Club Membership): _____________________________________________________
I am aware that photos of events may be taken and permit skater to be included in photos: Yes ______ No ______
I understand figure skating is a dangerous activity involving risk of serious injury and death. Despite my knowledge of these risks, I voluntarily agree to assume such risks and to hold harmless and free from any liability, injury or loss, the HERITAGE SKATING ACADEMY, its officers, directors, members or agents, and ice rink facilities the HERITAGE SKATING ACADEMY uses for practice or events. I give permission for emergency medical treatment to the skater should that become necessary. I agree to be bound by the bylaws and rules of the HERITAGE SKATING ACADEMY and agree to pay all membership, ice and coaching fees to remain a member “in good standing” with the HERITAGE SKATING ACADEMY.
Adult Member/Parent or Guardian Signature: __________________________________________________________ Date: _________
Junior Member Signature: _________________________________________________________________________ Date: _________
Make Check Payable To: Heritage Skating Academy ($30 Fee Applies to All Returned Checks)
Mail or Deliver Check and Application Form to:
Heritage Skating Academy
c/o Ice Box Sports Center 21902 Telegraph Road Brownstown Twp, Michigan 48183