Parent Name *

First Name

Last Name

Phone/Text Contact *

(###)

###

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Participant Name *

First Name

Last Name

Participant Birth Date *

MM

DD

YYYY

Waiver *

I acknowledge that Kelly Shock, and Instructors, will not be held responsible or liable for any accident or loss, however caused, and agree to release Kelly Shock. and assistant coaches from all damages or claims which may arise as a result of such accident or loss. I hereby give my permission to seek out any medical assistance my child (or adult) may require while attending the program. Note: The person who agrees to this waiver must be at least 18 years of age. A parent must acknowledge for skaters under 18. Waiver must be acknowledged in order to be registered.

I accept the terms and conditions

Media Release

By clicking the Media Release on the registration form, I grant permission to Kelly Shock and Instructors, to use my image or my skaters image (photographs and/or video) for use in Media publications including: ❏- Advertisements ❏- Email Blasts ❏- Website and/or Affiliates ❏- Social Media I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image. I am the parent or legal guardian of the below named child. I have read this release before clicking the registration form, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

I agree to the media release

I regect the media release

Payment *

I agree to send payment via E Transfer to sk8coach.kelly@gmail.com within 12 hours to secure my spot. If payment is not received I forefeit my registration cue.

I Agree