Twin Rinks Internet Registration Form Fax to (847) 821-7469
Last Name _____________________ Phone No. (Home) _______________ (Emergency ) ________________
Address __________________________________ City __________________________ Zip _____________
Email Address _______________________________________________________________
Ice Show Costume: Chest ________ Waist __________ Hips __________ Girth __________
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Skating Class Code |
ü |
Skating Class Title |
Fee |
Payment Plan-Y/N |
ü |
Registrants First Name |
Age |
Birth Date |
Sex M/F |
| NISI- | ISI Annual Membership includes accident insurance. (optional) |
($13) |
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Total Amount |
100% payment or 50% now and 50% by 03/01/10.
If you choose payment plan, 50% Deposit is required at registration. If balance is not paid by the above date,
I agree to pay the credit card charges charged to the credit card number listed below and a $25 late fee for each week that my payment is late:
Refunds prior to the first day
Payment Plan:
No refunds.
Full Payment: 75% refund less a $10 administrative fee.
Refunds on or after the first day
A full refund less a $10 administrative fee will be given to entry level participants if the child refused to participate during the first day. This applies only to Toddler, Tot 1 Beg, and Pre-Alpha I classes.
Payment Plan: No refunds. Upon notification of cancellation the entire unpaid balance will immediately become due and will be charged to the credit card.
Full Payment: 50% refund less a pro-rated per class fee for each class that has taken place up to the date of notification.
Waiver and Release
of All Claims
Please read this form carefully
and be aware that in registering yourself or your minor child/ward for
participation in this activity, you will be waiving and releasing all claims for
injuries you or your child/ward might sustain arising out of this and all future
activities at Twin Rinks Ice Pavilion, Inc.
"I recognize and acknowledge that
there are certain risks of serious injury to participants in this
activity and I agree to assume the full risk of any injuries, damages or loss
regardless of severity which I or my child/ward may sustain arising out of this
and all future activities. I agree to waive and relinquish all claims I or
my child/ward may have arising out of this and all future activities against
Twin Rinks Ice Pavilion, Inc. and its officers, directors, shareholders, agents,
servants, and employees. I do hereby fully release and discharge Twin
Rinks Ice Pavilion, Inc. and its officers, directors, shareholders, agents,
servants, and employees from any and all claims from injuries, damages or loss
which I or my child/ward may have or which may accrue to me or my child/ward
arising out of this and all future activities. I further agree to
indemnify and hold harmless and defend Twin Rinks Ice Pavilion, Inc. and its
officers, directors, shareholders, agents, servants and employees from any and
all claims resulting from injuries, damages and losses sustained by me or my
child/ward, and arising out of, connected with, or in any way associated with
this and all future activities. In the event of an emergency, I authorize
Twin Rinks Ice Pavilion, Inc's. officials to secure from any licensed hospital,
physician and/or medical personnel any treatment deemed necessary for my or my
child/ward's immediate care and agree that I will be responsible for full
payment of any and all medical services rendered"
I have read and fully understand the above program details,
payment requirements and waiver and release of all claims.
I agree to pay the credit card charges charged to the following
credit card:
Discover MC Visa _________ _________ _________ _________ CVVC ____ Expires ___/___/___
Signature
____________________________________________ Date
________________
Signature required of all participants 18 years or older, parent
or guardian signature for those under 18.
1500 Abbott Ct. · Buffalo Grove, IL 60089 · (847) 821-RINK · fax: (847) 821-RINX · www.TwinRinks.com
This page was last updated on Tuesday, June 21, 2011