SCW New Membership Application Form

<% @language="vbscript" %> SCW New Membership Application Form                                                The Skating Club of Wilmington's
                                     APPLICATION FOR NEW MEMBERSHIP
                                                         Please print clearly and fill out completely

Name:

Dr.
Mr.
Mrs.
Ms

______________________________________________________________________________________________________________
Last Name Legal First Name (and spouse) Middle Initial

Home Address:

___________________________________________________________________________________________________________
Street City State Zip

E-mail address: *______________________________________________________	Publish e-mail in Member Directory? □ Yes □ No
*By providing your email address, you agree that SCW may provide you, by electronic mail, notices required by law and SCW's governing documents.

Home Phone:	Member:	( ) _______________	Work Phone:	( ) _______________	Cellphone:	( ) ________________
Home Phone:	Spouse:	( ) _______________	Work Phone:	( ) _______________	Cellphone:	( ) ________________

Children in Household (under 21 years of age) and birth dates:

List legal name on left and birthday on right: → List birth date(s) here:

(1)____________________________________________________________ → (1)_________________________________________________

(2)____________________________________________________________ → (2)_________________________________________________

(3)____________________________________________________________ → (3)_________________________________________________

Check ICE USE FEES Category desired and indicate if Individual (I) or Family Multiple (M).
2011-2012 Annual Dues of $160 + the following fees: _____ 10 Sessions/Month @ $132/Mo. _____ 20 Sessions/Month @ $236/Mo. _____ 40 Sessions/Month @ $350/Mo. _____ Unlimited Individual @ $465/Mo. _____ Social Membership (no skating) @ $100 Annual Dues 2011-2012 Annual Dues of $176 + the following fee: _____ Basic Member with Walk-on Fee of $14/skater/session or purchase ticket books of 10 sessions for $140	Please check which is applicable, (I) Individual, (M) Multiple or Family, (S) Social. _____ (I) or _____ (M) _____ (I) or _____ (M) _____ (I) or _____ (M) _____ (I) xxxxxxxxx _____ (S) xxxxxxxxx
Note: Full payment of Annual Ice Fees on September 1 will receive a 5% discount.

Names of family members who will be skating:

______________________________________________________________________________________________________________

Business, professions, skills, interests of adult applicant(s):

_____________________________________________________________________________________________________________

Past association with SCW:

_____ Public Session
_____ Guest

_____ Hockey
_____ Summer School

_____ Public Lesson
_____ Other

If applicable: Name(s) of coach(es) who will give private lessons:

____________________________________________________________________________________________________________

Highest USFSA tests passed:

Figure: _______________________________
Dance: ________________________________
Moves in the Field: __________________

Free Skating: ________________

Pairs: _________________________

Home Skating Club: ___________________________________________________________ USFSA Number: ___________
If you are transferring from another USFSA Club, please have a club officer or test chairperson send a letter indicating that you are a member in good standing at your home club.
I (We) hereby apply for membership in SCW and have included the $160 Member Annual Dues, plus, (if applicable) the first month's payment of any Ice Use Fees category (10, 20, 40, etc.) chosen.
I (We) agree to comply with the rules and by-laws of the Club (See SCW Handbook).
I (We), understand that ice skating is a dangerous sport, and hereby waive any claims for damages sustained in the course of ice skating at the Skating Club of Wilmington.
I (We), understand that photos and videos may be taken of skaters and others at SCW during regular and special skating activities. These images may be used for publicity for SCW, which may include SCW's website, print and internet publications, and media. In some instances, skaters are identified. I will notify SCW if I have any objection to having myself or a family member photographed, videotaped or identified.

Adult Signature: ________________________________________ Amount Enclosed: ______________ Date: _____________

(If printing off the internet, we suggest instructing the printer to print in landscape mode.
You'll have a 2-page form that will look better and give you extra room to print.)