For Club Use Only

Dues                                            

Paid                                             

Check # or Cash                        

Initials                                         

Penguin Figure Skating Club

2008-2009

Membership Application

 

NAME (Adult Member - 18 or over)                                                                            HOME PHONE                                                            

ADDRESS                                                                                                                                                                                                          

                       Street address                                                city                                           state/zip code

E-MAIL ADDRESS                                                                                               SPOUSE NAME                                                                

TYPE OF MEMBERSHIP: (circle one)        BASIC         BASIC FAMILY         ASSOCIATE         FRIEND/FAMILY  

                                                          JUDGE       COACH       HONORARY        COLLEGIATE       SYNCHRO

 

Please list names, birth dates and skating status of all skating club members in your family:

NAME

BIRTH DATE

SKATING STATUS (circle one)

Adult Member as named above

 

amateur*   professional    recreational    non-skating

Spouse -

 

amateur*   professional    recreational    non-skating

Skater -

 

amateur*   professional    recreational    non-skating

Skater -

 

amateur*   professional    recreational    non-skating

Skater -

 

amateur*   professional    recreational    non-skating

Skater -

 

amateur*   professional    recreational    non-skating

* Indicates an amateur skater who is currently considered a competitive skater.

 

Fees and Membership Information:

 

Type of Membership:

FEES

Notes About Membership Type

Basic

$200

Includes USFS number, rights to club test sessions, fall exhibition, winter show, other club sponsored events, and ice time.

Basic Family

$260

For families of two or more skaters or adult members, includes all benefits of the basic membership.

Associate

$135

Skaters must recognize another USFSA club as home club.  Fee includes club ice, rights to club test sessions, fall exhibition, winter show and other club events.  Other restrictions may apply.  See Constitution and By-Laws.

Friend and Family

$50

This is a Non-skater membership – designed to sponsor the PFSC and its skaters.  Includes a USFS number and subscription to “Skating” magazine.

Coaches

$45

Includes rights to teach on club ice time. 

Honorary

$0

Penguin Figure Skating Club grants this status through its Board of Directors and is maintained as long as the member remains in good status with USFS.  Club ice packages are not included in an Honorary membership but may be purchased.

Judges

$0

For judges and trial-judges

Collegiate

$50

Designed for Penguin members who wish to continue their Penguin membership into their collegiate years.  Includes USFS number, subscription to “Skating” magazine, and the right to participate in club exhibitions and special events.  Does not include ice time.

Synchro

$25

Skater must be a member of the Steel Blades synchronized skating team and recognize another USFS club as home club.

 

                The undersigned hereby make(s) application for membership in the Penguin Figure Skating Club, Inc., and agree(s), if admitted to membership, to be bound by and subject to the Constitution and By-Laws of, as well as any and all rules and regulations promulgated by, the Penguin Figure Skating Club, Inc., as the same now exist or may hereafter be enacted or amended.

 

Date                                                            Signature of Applicant                                                                                                                 

 

Please return completed form and payment to the Penguin FSC mailbox or mail to:  Steel Ice Center attn: PFSC, attn: Membership Chairperson at 320 East First Street, Bethlehem, PA  18015. 


RELEASE OF LIABILITY

AND AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

 

By signing the Release and Authorization form, express permission is hereby given for the following minor children, namely (provide full legal names of minors):                                                                                                                                                                                    

                                                                                                                                                                                                                             

                                                                                                                                                                                                                             

to participate in all practice sessions, club competitions and other activities of the Penguin Figure Skating Club, Inc., during the Club’s 2008-2009 season, and in connection therewith, the undersigned agrees(s) and consent(s) to the provision of transportation for the minor(s) to and from the site of any such activities by Penguin Figure Skating Club, Inc.’s officers, professional coaches, committee volunteers and/or volunteer drives; and further, expressly consent(s) to and authorizes the furnishing of emergency medical treatment to the aforesaid minor(s), if necessary, including, but not limited to diagnostics and testing, blood transfusion, x-rays, splinting, casting, administration of medicines, and/or emergency surgeries, by any health care provider duly licensed by the Commonwealth of Pennsylvania; and finally, for the undersigned as well as the said minor(s), the undersigned, and his/her/their respective heirs, executors, administrators, successors, and assigns, do hereby remise, release and forever discharge Penguin Figure Skating Club, Inc. , its officers, professional coaches, committee volunteers and volunteer participation in the above-referenced activities (except in the case of intentional injury to the minor by, or gross negligence toward the minor on the part of, Penguin Figure Skating Club, Inc., its officers, professional coaches, committee volunteers and or volunteer drivers).

 

The signature of an adult skater set forth below is intended by such skater, and shall be conclusively deemed to evidence consent to emergency medical treatment of such adult skater, as well as to constitute a release of liability on the part of Penguin Figure Skating Club, Inc. its officers, professional coaches, committee volunteers and volunteer drivers, and each of them, to such adult skater, fully in such manner and to such degree as is set forth hereinabove with respect to minor skaters.

 

        In witness whereof, this Release and Authorization form has been duly executed this  ________ day of _______________________, 2008/2009.

 

                                                                                               

(Adult Skater’s Signature)

                                                                                               

(Parent/Guardian’s Signature)

                                                                                               

(Parent/Guardian’s Signature)

 

 

 

 

 

 

 

 

 

(Note:  If only ONE parent or legal guardian signs this form, his or her signature shall constitute an affirmative representation of full legal authority so to act without his or her obtaining the signature of a non-signing parent, guardian, or any other person)

 

 

 

 

 

HEALTH INSURANCE INFORMATION

(This Section MUST be Fully Completed Before Submission)

 

Health Insurance Company Name:                                                                                                                                                                        

Group Name (If Applicable):                                                                                                                                                                                 

Group Member/Primary Insured:                                                                                                                                                                           

Policy No.                                                                                                   ID No.                                                                                              

 

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PLEASE NOTE: NO APPLICATION FOR MEMBERSHIP IN THE PENGUIN FIGURE SKATING CLUB, INC., WILL BE PROCESSED UNLESS BOTH SIDES OF THIS FORM ARE COMPLETED WITH ALL REQUESTED INFORMATION BEFORE BEING RETURNED.  FAILURE TO SUPPLY REQUESTED INFORMATION COULD, THEREFORE, DELAY MEMBERSHIP REGISTRATION, AND POSSIBLY AFFECT ELIGIBILITY FOR COMPETITION AND TESTING PURPOSES.

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