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, Mark Fitzgerald , Steven Cousins, Tampa Bay Figure Skating Club, 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 Tampa Bay Figure Skating Club to use all photos or videos taken of me/my child during the program.

I agree

Please check which instructor(s) you would like to book lessons with:

Private lesson with Dan

Private lesson with Mark

Private lesson with Steven