LEARN TO SKATE PLYMOUTH

                                            Since 1974

                                                            www.learntoskateplymouth.com

                                       c/o Margot Marino    17 Sushala Way, Plymouth, MA 02360       (508) 746-5668  

 PLEASE CHECK YOUR CHOICE OF CLASS at the PLYMOUTH RINK, LONG POND RD.

      LEARN to SKATE: SESSION 4      Beginners & Advanced, Ages 5 & up

                            Begins  Monday, February 20, 2012 - 7 weeks

                            Please Check One:

                                              4:30­­­­­pm to 5:25pm Large group _____($125) 

                                              5:30pm to 6:20pm Small group(5 to 1) ________($145)

 CHILD’S NAME_____________________________________________AGE_____DOB_____________

  PARENT’S  NAMES_________________________________________________________________

  ADDRESS________________________________________________________________________

  CITY___________________ZIP___________ GENDER: MALE_____ FEMALE_____

  PHONE: home#__________________________cell#________________________ work#___________________

  E-MAIL_____________________________________________________________________________________

  From where did you hear about this program?_____________________________________________________

    PLEASE CHECK:       (A) BEGINNER______

                                (B) CAN SKATE_____

                                (C) HAS PASSED BADGE:   USFS BASIC #_____ FREESTYLE #________ISIA#_________TOT (AGE 3-6) #______

I, the parent or guardian of the above named child, have been made aware that LEARN TO SKATE is not covered by medical insurance for persons injured while taking part in the Learn to Skate Classes. In consideration of my child’s upcoming participation, I declare, that to the best of my knowledge, the above named child is physically able to participate in the Learn to Skate Classes, and that I hereby hold LEARN TO SKATE, its servants, and employees harmless from any injury the above named child may incur while taking part in the Learn to Skate Classes. Further, in the event that I may not be reached, I am delegating authority in advance of any specific diagnosis to the doctor/clinic/hospital to exercise their best judgment as to any necessary medical/surgical treatment that my child may require. I agree to hold harmless the LEARN TO SKATE, its servants, employees, and any doctor/clinic/hospital treating my child for failure to obtain my consent.

  PRINT NAME OF PARENT/GUARDIAN_______________________________________

  SIGNATURE OF PARENT/GUARDIAN__________________________________________________ INSURANCE CARRIER or HMO___________________________________                                                                    REFUNDS WILL NOT BE GIVEN AFTER THE SECOND LESSON. THERE WILL BE A $15.00 FEE FOR RETURNED CHECKS.  Weather related cancellations will not have a make-up lesson.    

Please  MAKE CHECKS PAYABLE TO:  MARGOT MARINO,  17 Sushala way, plymouth, ma. 02360

 For office use only:     Feb. Session 4    2012     Badge Level__________   

Amount ___________ Cash_____Check_____Check #___________ Date ___________