38 Coal Street
Wilkes-Barre, PA. 18702
570-510-3800
MEMBERSHIP APPLICATION
NAME..........................................................................................DOB..................................
STREET ADDRESS...............................................................................................................
CITY, STATE, ZIP...................................................................................................................
EMAIL...................................................................................................................................
HOME PHONE.............................................................................CELL PHONE.....................
SPONSOR.............................................................................................................................
HOME CLUB..........................................................................................................................
USFSA#.................................................................................................................................
SIGNATURE of SKATER (over 18)............................................................................................
PARENT or GUARDIAN (under 18)...........................................................................................
RELATIONSHIP to SKATER....................................................................................................
PHOTO RELEASE
I agree and give my consent for the use of my photo by the Diamond City Figure Skating Club including video and/or photographs. Signature of member or adult/guardian, if member is under the age of 18...................................................................................DATE...............................
I disagree and do not give my consent for the use of my photo by the Diamond City Figure Skating Club including videoand/or photographs. Signature of member or adult/guardian, if member is under the age of 18..........................................................................DATE...............................
