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BROCHURE LINK

http://www.ci.plymouth.mi.us/DocumentView.aspx?DID=577

First name

Last name

Address

City, Zip

phone number

Fathers name

Mothers name

please circle one

SAM I SAM II SAM III ADULT

BASIC I BASIC II BASIC III BASIC IV

HOCKEY I HOCKEY II HOCKEY ADV

Please circle one

Monday/Thursday/Saturday

Back to Basics Skating School, the Plymouth Cultural Center, Kathy Markovich, her coaching staff and arena staff are hereby relieved of any and all responsibility for any injury sustained by the above named skater while participating in, or in transit to or from, any function or activity sponsored by the Back to Basics Skating School and or the Plymouth Cultural Center.

Any and all claims against the Back to Basics Skating School, the Plymouth Cultural Center, Kathy Markovich, coaches, and arena staff, recipitated by any such injuries are hereby waived.

Permission is granted to the Back to Basics Skating School, and the Plymouth Cultural Center to obtain any necessary emergency services at the expense of the undersigned, should injuries be incurred.

Permission is granted for photographs and pictures of me, my child(ren) and/or family members to be taken and released for Back to Basics Skating School and the Plymouth Cultural Center group lesson.

_______________________________________________________________ Signature

__________________________________________________ Date