Academy of Speedskating Excellence (ASE

Academy of Speedskating Excellence (ASE) PRESENTS SUMMER GOALS, WINTER DREAMS Development Camp 2014
Sunday Check-in starting 2pm-Friday Checkout 9am, July 20-25 @Lake Placid, New York COACHES: Katherine Reutter, Short Track,World Champion/Olympic Medalist; Kreg Greer, Long Track, Former US National team member, and more! First Name_____________________ Last Name _______________________________ Gender: M___ F___AGE: ___Grade: ____ Date of Birth: D_____/M_____/Y______ Email Address: ___________________________________________________________ Address_________________________________________ City: ___________________________ State: ______ Zip: __________ Sport(s):________________________Personal best: (500m<1min)____________Adult T-‐shirt Size: S____M____L___XL__2XL__ USS Member #__________ * Must be 12 by July 1, 2014, U-‐12 by permission *Camp limited to 30 skaters,wait list available ASE Team Member $350:____Non-‐ASE Speed Skater $400____*Fees include ice, coaching, camp t-‐shirt, training, room, & board (u-‐12 must find their own arrangements) Parent/Guardian First Na-‐
me___________________________________ Last Name:_____________________________________ Parent day phone_______________ Home Phone_____________ Cell Phone_____________Email_________________________ Health Insurance Company: __________________Policy #:______________Pre-‐existing conditions________________________ Name of Emergency contact (other than parents)__________________________Emergency Phone________________________ 1.
I the undersigned parent/guardian of the individual named above, a minor, do hereby agree to allow the individual named herein to participate in the aforementioned activity and authorize and appoint the program directors and/or instructors as Attorneys in Fact and agents for the undersigned to consent to medical, surgical
and/or dental examinations, in addition to any and all other treatments that may be deemed necessary by
medical personnel. It is understood that participation involves an element of risk and danger of accidents.
Knowing those risks, I hereby assume those risks. In addition, I understand that by signing this agreement, I
hereby release and discharge ASE/Pettit non-‐profit corp. from any and all liability resulting in injury associated
with the camper’s participation in this activity. I understand it is my responsibility to inform camp personnel of
any medical conditions, allergies, food restrictions or any other special needs my son/daughter may have. In
the absence of a parent guardian’s signature below, payment of fees and participation in the program shall
constitute acceptance of the conditions set forth in the release. 2.
I give ASE/Pettit non-‐profit corp. full permission to use my child’s photo in future promotional brochures, poster,
and/or website. 3.
I have read and understand the ASE/Pettit non-‐profit corp. cancellation policy. 4.
I give ASE/Pettit non-‐profit corp. full permission to transport the camper to other facilities as needed.
___Check if you do not want your child to receive over-the-counter medications at camp (i.e. Tylenol, Advil,
etc) Athlete Signature (I have read and understand the terms above)_______________________________________Date:________ If under 18, Parent Signature (I have read and understand the terms above)______________________________Date:_______ Checks: Mail/Payable to the Pettit National Ice Center, Inc. (Memo-‐ ASE) Office: Date_____ Check#_______ Amount____ Fax:414-‐
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266-‐0122 500 S. 84 St., Milwaukee, WI 53214

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