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• u'�1lll�r �� Ilt� A � <br />. <br />� r <br />]DAYTIME SIKATINO SCHOOL <br />WI <br />Program # <br />9100.597 <br />9100.598 <br />9100.599 <br />NTE R 2013 - 9 <br />Thursdays, Januar <br />(No class <br />Time <br />10:00am- 10:30am <br />10:30 am- 11:00am <br />11:00am- 11:30am <br />WEEK SESSION <br />73 -March 7, 2013 <br />on Jan 31) <br />Level <br />Preschool 3 -4 years old <br />Adult Skating Lessons & Practice ice* <br />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 />Fee: Regular-$76.00 Roseville Resident - $67.00 <br />REGISTER ONLINE @ www.cityofroseville.com/skatingcenter <br />THERE ARE NO PROVISIONS FOR MAI {E UP CLASSES! <br />An $8.00 processing charge will be added to all cancellations. <br />------------------------------------------------------------------------------ - - - - -- <br />Participants <br />Parent /Guardian <br />Name: <br />Phone: Name: <br />Home Address: <br />City: State: Zip: <br />Gender( circle)- F M Rirthdate- Status- New Student ReturmnQ Student <br />Program # Program Name: Test Passed: <br />hDoes <br />participant have any disability, allergy or special need of which we should be aware? Explain: <br />p r <br />U <br />a> Lo <br />LO <br />Liability Waiver: I understand that participation in this activity is completely voluntary. I recognize that there are risks in my participation in this <br />U g r <br />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 />Nmy <br />heir, executors, administrators and assigns, to release and discharge the City or Roseville, sponsor (s) of the event or activity, and their <br />Q) w <br />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 />oo <br />participation in this activity. <br />N � <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 />requests to participate in activities. You may refuse to provide such information, but such a refusal may affect your ability to participate. The <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 />Departments of the City. <br />Signature: <br />Date: E -Mail: <br />Fee Paid <br />Date Paid <br />Check # <br />B <br />Visa or MasterCard #: <br />I Exp Date <br />►0; <br />N <br />O <br />W <br />d <br />A� <br />n <br />O <br />O <br />