Please type in all available boxes, print page, then sign and Fax to 301-315-5673

U.S. FIGURE SKATING "BASIC SKILLS" GROUP LESSON REGISTRATION

Student First Name: Student Last Name:
Parent First Name: Parent Last Name:
Gender: M F Email:
Date of Birth: Age:
Address:
City: State: Zip:
Telephone (H) : - - Telephone (W) : - -

Class Level Day Time
Option 1
Option 2

Important - Read and Sign
I hereby release Rockville Ice Arena and all employees herein from all responsibility for injuries incurred at Rockville Ice Arena. I understand that helmets are required for all children ages six and younger and are recommended for everyone. I understand that injuries can occur during ice skating and that I (or my child) accept the risk willingly.


____________________________                ____________________________
Print Student/Parent Name (if under age 18)                Student/Parent Signature (if under age 18)
PAYMENT INFORMATION
Credit Card # Expiration Date:

_________________________________
Authorizing Signature

FOR OFFICE USE ONLY
Date Paid:_____________
Amount Paid:___________
Payment Method:________
Skate Pass #:___________
Cashier Initials:__________
Please note we only accept:
Visa and MasterCard