Register | SK8HERS INC

Student First Name:

Student Last Name:

Student Date of Birth:

Month

Day

Year

Student Address:

School/Homeschool:

Student ID #:

Grade Level:

Shoe Size (Please specify if it's a youth size or women size):

In order to participate in SK8HERS Inc. non-traditional programming, your student must own a pair of quad roller skates. Does she have a pair?

YES

NO

Student SK8HERS INC Membership status:

New Member

Current (Previous School Year)

Past (over 1 year ago)

What is your daughters roller skate level?

Level 0 - I can’t skate at all

Level 1.- I can skate a little but I still need help

Level 2- I can skate on my own without any help

Level 3- I can skate on my own forward, skate backwards a little, turn around backwards a little

Super Skater- I can skate forwards, turn around backwards and skate backwards on my own

(1) Parent Name:

(1) Parent Phone Number:

(1) Parent Home Address:

(1) Parent Email Address:

(2) Parent Name:

(2) Parent Phone Number:

(2) Parent Email Address:

(2) Parent Home Address:

Students' Emergency Contact Name:

Students' Emergency Contact Phone Number:

List students' past and current health conditions and/or allergens:

List students' past and current prescribed medications (if any):

Please list students' past and current physical restrictions (if any):

Students' Primary Physician:

Students' Primary Physicians Address:

Students' Primary Physicians Phone Number:

Students' Last Physical Exam Date:

Students' Health Insurance:

Responsible Party Name(s):

Responsible Party Phone Number (s):

Do you consent to signing a liability and assumption of risk agreement, informed consent and acknowledgement form, medical authorization release form and a media release form?

Yes

No

A one-time registration fee of $25 will be due at time of orientation. Do you agree to pay this fee?

Yes

No

A membership fee is due monthly per member; do you agree to pay this fee? (Parent/Guardian will be emailed more details once selection of members has been processed)

Yes

No

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