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V IL <br /> ps� SKATING CENTER <br /> 1D .& Y71r. XMIE SMA71r1wek SC 00 <br /> WINTER 2012 to 8 WEEK SESSION <br /> Thursdays, Januar 5 - March 8 2012 <br /> (No classes on Jan . 26&Feb. 23) <br /> Program # Time Level <br /> 9100.548 10:00am-10:30am Preschool 3-4 years old <br /> 9100.549 10:30am-11:00am Adult Skating Lessons & Practice ice* <br /> 9100.550 1 1:00am-1 1:30am 5 years old to early teen <br /> *Adult skating lessons are being offered on half the ice while practice ice is available for registered skaters only. <br /> Adults are highly recommended to wear protective gear including helmets. <br /> ROSEVILLE RESIDENT FEE = $60,00 NON=RESIDENT FEE = $68.00 <br /> REGISTER ONLINE 0-- .Cit ofroseville.Com/skatin Center <br /> NZ.;0-F <br /> Y g <br /> THERE ARE NO PROVISIONS FOR MAKE UP CLASSES! <br /> An$8.00 processing charge will be added to all cancellations. <br /> ------------------------------------------------------------------------------------ <br /> Participants Parent/Guardian <br /> Name: Phone: Name: <br /> Home Address: City: State: Zip: <br /> Gender(circle): F M Birth New Student Returnino Student �• <br /> Program# Program Name: Test Passed: <br /> N <br /> Does participant have any disability,allergy or special need of which we should be aware? Explain: <br /> � � Nco <br /> T <br /> 3 <br /> 4-a� <br /> a z Liability Waiver:I understand that participation in this activity is completely voluntary.I recognize that there are risks in my participation in this <br /> � T activity.I agree to accept those risks.I also agree,in consideration for my being allowed to participate in this activity,and on behalf of myself, �• <br /> :> N my heir,executors,administrators and assigns,to release and discharge the City or Roseville,sponsor(s)of the event or activity,and their <br /> N T officers,employees,agents,successors and/or assigns from liability for any and all injury,damage or loss that is or may arise from my <br /> N <br /> 60 0� participation in this activity. <br /> Data Practices Act Notice:Pursuant to the Minnesota Government Data Practices Act,you are being requested <br /> to furnish certain information that is classified as private under the Act.The City collects such information in order to properly process <br /> ME requests to participate in activities.You may refuse to provide such information,but such a refusal may affect your ability to participate.The V� <br /> information will be maintained by the City Park and Recreation Department,and may be accessible to anyone in the Department,or in other <br /> O <br /> Departments of the City. O <br /> Signature: Date: E-Mail: <br /> Fee Paid Date Paid Check# By <br /> Visa or MasterCard#: Exp Date <br />