Skater Name *

First Name

Last Name

Birthdate of Skater *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell *

(###)

###

####

Parent or Guardian *

First Name

Last Name

Liability Waiver *

Accident/Liability Release I (We: the participant's and the parent's), do hereby release Dan Hollander, Fort Collins Figure Skating Club, EPIC and all directors, staff and instructors of personal property losses, accident or injuries of any kind occurring while I/my child is participating in any and all programs. I also authorize Dan Hollander and Fort Collins Figure Skating Club to use all photos or videos taken of me/my child during the program.

I agree

Please check all that is appropriate

Create a new routine with Dan

Have Dan enhance a program already done

I have signed up for the seminar

I do not plan to take the seminar and would only like private lessons

Please provide the coach you would like as your main contact for your showcase routine

In order to be as efficient as possible, Dan would like to reach out in advance to your contact coach to be prepared.

First Name

Last Name

Which type of showcase number are you interested in?

you may check more than one

Dramatic

Light Entertainment

Group Number