Skate IA 2021 Renewals

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Team name   First name   Last name   Email address   Date of birth    MM 01 02 03 04 05 06 07 08 09 10 11 12    DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    YYYY 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922    Membership type Choose one Adult individual Skate School Minor (17 and under)   Membership type Choose one Associate Membership Inactive Status/Special With Insurance Without Insurance Choose one With Insurance Choose one With Insurance Without Insurance   Event entry fee TBD

Skate school name (if applicable) Website (if applicable) Street Address  *   City  *   State  *   Zip Code  *   Country  *   Primary phone number (For Skate IA use only)  *   Alternate phone number (for Skate IA use only) Levels achieved with Skate IA Level 1 NoYes Level 2 NoYes Slalom freestyle NoYes Skate Park NoYes Skateboard NoYes Other (specify) I am a Skate IA Examiner (I can certify instructors) NoYes How many students you expect to teach in 2021 (total number of students, not total classes) (best estimate)  *   Estimated # of classes to teach in 2021 total (10 students will take 40 classes so answer is 40)   How many classes did you teach last year (40 students each took 4 classes = 160 classes  *     Past year: Estimated number of students for 2020 (assumes each student counts as 1, regardless of classes taken)  *     You generally skate Inline, Quads?  * Choose one: skateboard Inline Quads   You MUST maintain insurance for your teaching. Some members do not teach so you won't need it. Please select accordingly  * Choose One I am buying SkateIA Insurance I maintain Other Insurance (provide to SIA office) I am not intending to teach in 2021   All 2021 members must be safe sport trained. You must have it completed by 30 days from registration or the day your insurance goes into effect.  * Choose one Yes I am Safe Sport Trained (send us your certificate) I will be taking the training (AthleteSafety.org)

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Please review the waiver provided by the event organizer and click the check box below to accept it. Print waiver WAIVER AND RELEASE OF LIABILITY AND INDEMNIFICATION AGREEMENT In consideration of participating, in any way, as a member in the (SKATE IA) or any of its events and activities, I acknowledge and agree that: (1) There are risks involved with inline skating, roller skating and skate boarding. Injuries, including permanent paralysis and death, sometimes occur. (2) I assume all risks of injury, even injuries caused by the negligence of SKATE IA or its owners, officials, directors, employees, advisors, independent contractors or other participants. (3) I will have my students wear proper safety equipment, including helmet, wrist protection, and will encourage them to wear knee and elbow pads. I will teach my students at their knowledge and skill level, which includes progressive instruction appropriate to the class. I will teach safe skating habits and safety practices. (4) I, for myself, and on behalf of my heirs, assigns, personal representatives and next of kin, hereby agree to defend (including the payment of attorney fees), indemnify and hold harmless SKATE IA and its owners, officials, directors, employees, advisors, independent contractors, as well as, its advertisers, sponsors and agents from all claims (including lawsuits) against them arising out of my acts or omissions or claims brought by me or my heirs, assigns, personal representatives and next of kin. I have read, and understand, this Waiver and Release of Liability and Indemnification Agreement. I have read, and understand, the SKATE IA Safety Guidelines and Requirements. I agree to maintain insurance at all times if teaching either as a volunteer, for free or for paid classes. If I purchase insurance, it is my responsibility to understand the policy terms. I agree to review and be responsible for the "Guidelines for Members" which will be sent via webscorer to me when my registration is complete. I affirm all information I provided to SKATE IA is completely correct. I accept the terms of the waiver Name of parent or guardian who approves this activity