JUNEAU SKI CLUB

DEVO
Enrollment Form 2009/2010
Athlete Information
Last Name: First Name:
Sex: Date of Birth: Age:
School: Grade:
Mailing Address:
Residence Address:
Home Phone: Work Phone: Cell Phone:
E-mail:
Parent(s) or Guardian(s)
Please check here if USSA fees have been paid for 2009/2010
USSA Alpine Competitor License #: Youth Ski League License #
Devo Team 1day, Includes 3, 3day camps $ 500.00
______
Juneau Ski Team Membership (one per family) $ 30.00
PRIOR TO PARTICIPATION IN DRY LAND FITNESS TRAINING A DEPOSIT
OF $200.OO MUST BE PAID AND THE MEDICAL RELEASE TURNED IN.
Total Paid: Total Due:
Check Number:
Individual payment plans are available and must be set up in advance with JSC Treasurer.
Payments can be sent to: Juneau Ski Club P.O. Box 32358 Juneau, Alaska 99803
 Juneau Ski Club
DEVO
Release Form 2009/2010
PLEASE READ AND COMPLETE THIS FORM

Statement of Risk: I, understand that alpine skiing carries

significant risk of personal injury. I know there are natural and man-made obstacle or
hazards, surface and environmental conditions and risks which in combination with a
racer’s actions could cause severe or occasionally fatal injury. In participating in the
Juneau Ski Club programs and skiing at Eaglecrest, such dangers are recognized and
accepted whether they are marked or unmarked. I hereby release and hold harmless the
Juneau Ski Club it’s coaches, race officials, USSA, USSA Alaska Division and any
person connected with the above program during participation in any events, use of ski
Club facilities or equipment, team travel or any events associated with the Juneau Ski
Club Programs.
ENROLLMENT OF NAMED ATHLETE

By signing below, I hereby agree to enroll the athlete named above with the Juneau Ski
Club and agree to pay all membership dues and program fees for named athlete by
December 1, 2009. Individual payment plans must be arranged with the Treasurer.

Code of Conduct

Parent’s Acknowledgement: I hereby certify that as a parent or guardian of the named

participation athlete that I acknowledge and agree to abide and have the named athlete
abide, by the code of conduct as written in the Juneau Ski Club Handbook.

Athlete Acknowledgement: I acknowledge that I have read the code of Conduct as

written in the Juneau Ski Club Handbook and I agree to all the rules and regulations.

Release Authorization for Medical Attention

I hereby grant permission for a doctor to perform any diagnostic procedure, anesthetic,
operation, or curative remedial procedure they deem necessary or advisable for the care
and treatment of the above named skier.

Please Read and Understand above BEFORE signing.

Signature of athlete: Date:

Signature of parent or guardian: Date:

 MEDICAL EMERGENCY CONSENT FORM

If your child needs emergency medical care and you aren’t available to give
formal consent to medical authorities, care may be unnecessarily delayed. To protect
your child, leave a completed EMERGENCY CONSENT FORM.

Parents or Guardian’s Name:

I/we hereby authorize Juneau Ski Club to give consent for all medical and pr surgical
treatment that may be required for our child during our absence.

CHILD’S NAME:

CHRONIC ILLNESS:

CURRENT MEDICATION:

TETANUS IMMUNIZATION: (date)

ALLERGIES:

Parent’s or Guardian’s Name:

Home Address of Parent/Guardian:

Home Phone: Cell Phone:

Employer: Phone:

Health Insurance Co.: mcm#

S.S. # Group#

Nearest Relative: Phone

Signature of Parent/Guardian Date