MITEY MITE SKI TEAM 2010 ENROLLMENT FORM Athlete Information
First Name_____________________________________ Last Name Sex School Mailing Address City__________________________ Date of Birth _____________________________ ________________________
Home Phone_____________________________________________________________ Work Phone(s)___________________________________________________________ E-mail Address ___________________________________________________________ Heads of Household _______________________________________________________
(First and last names of both parents or guardians where the athlete resides)
Home Address ___________________________________________________________ City__________________________ Zip_____________________
Have you completed and signed the attached Medical Release? __________________ ENROLLMENT FEES (Please make check payable to Juneau Ski Club) 2010 Mitey Mite Program (per athlete)……..………. $200
(Includes $20 JSC Family Membership)
Please send forms and payment to: Juneau Ski Club Mitey Mites 9356 Turn St Juneau AK 99801
If you are planning on enrolling on January 9th, 2010 please call 789-5761 so we know you are coming.
Enrollment Form and Payment Due on or before January 9, 2010. For more information call Mike Satre at 789-5761. This activity partially funded by the Citizens of the City and Borough of Juneau, Alaska.
Mitey Mite Ski Team
2010 Medical Release Form January 9, 2010 to March 14, 2010 Please read and sign.
Statement of Risk: I, __________________________________ understand that alpine skiing carries significant risks of personal injury. I know there are natural and manmade obstacles or hazards, surface and environmental conditions and risks which in combination with a racer’s actions could cause severe or occasionally fatal injuries. In participating in the Juneau Ski Club programs and skiing at Eaglecrest, such dangers are recognized and accepted whether they are marked or unmarked. I hereby release and hold harmless Eaglecrest Ski Area and it’s employees, the Juneau Ski Club, it’s coaches, race officials, USSA, USSA Alaska Division and any person connected with the above program during participation in any Juneau Ski Club activity, including but not limited to training, racing, work parties, social events, use of Eaglecrest Ski Area and Juneau Ski Club facilities or equipment, team travel, or any social events associated with the Juneau Ski Club programs.
Release Authorization for Medical Attention
I hereby grant permission for a doctor to perform any diagnostic, anesthetic, operation, or curative remedial procedure they deem necessary or advisable for the care and treatment of the above named skier.
Enrollment of Named Athlete
By signing below, I hereby agree to enroll the athlete named above with the Juneau Ski Club, and agree to pay all membership dues and program fees for named athlete by January 9, 2010.
Please Read the Above Information before Signing
Signature of Child Residence Address Mailing Address Phone Numbers Personal Physician Medication (if any) Medical History Medical Insurance Co. Policy Number Insurance Company Phone #
Signature of Parent or Guardian
Enrollment Form, Medical Release & Payment Due on or Before January 9, 2010. This activity is partially funded by the Citizens of the City and Borough of Juneau.