Chicago Figure Skating Club

2016-2017 New Member Application

Item / Your Information - please print clearly
Referred By:
US Figure Skating No. (if a previous/current member)
Home Club / Chicago FSC /  Other:
First Family Member? /  Yes 2nd Family Member
First Name - Initial - Last Name
Street Address
City - State - Zip
Home Phone Number / () unlisted
Cell Phone Number * / ()  unlisted
E-mail address / @ unlisted
Gender /  Male Female
Birth Date (mm/dd/yyyy)
USA Citizen /  Yes No
Primary Activity (check one) /  Parent/Guardian  Coach  Competitive Skater
 Recreational Skater  Club Officer / Board Member  Other
Check Others That Apply: /  Adult Skater  Synchro  Collegiate  Competitive Skater  Coach  Recreational Skater  Parent/Guardian  Club Official
Synchro Member /  Yes  No  Synchro Coach  Synchro Parent
Synchro Club and Team Level
For Jr. Member. - Parent Name
Parent Name
US Figure Skating status** / Eligible Ineligible Restricted

* For juniors, phone numbers are for parent/guardian

** Definitions: 1) RESTRICTED: someone who receives money for owning or managing an ice show, arena, or a non-sanctioned competition 2) INELIGIBLE: someone who participates in an event that is not sanctioned by US Figure Skating, ISU, or ISI.

I certify that the applicant is eligible to be a member of the US Figure Skating under the current by-laws and rules of the US Figure Skating. If the application is approved, I agree to abide by, and to have the applicant abide by, the rules of the Chicago Figure SkatingClub. As a (parent or guardian of a) member of the Club, I agree to hold harmless the Chicago Figure Skating Club, its officers, directors & representatives from any and all liability for loss, damage, and/or injury of any manner arising while participating (or while my child participates) in Club activities. I acknowledge (1) that all Club privileges of a member may be suspended for violation of Club or US Figure Skating rules or if financial obligations to the Club are not timely paid; and (2) that I shall pay $35.00 for any check returned "NSF" and $5.00 for each additional billing. The Club is authorized to publish the member's name and/or photo in newsletters, the CFSC directory, websites and bulletin boards.

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Signature of Applicant Signature of Parent/Guardian Date

Note: If the applicant is under 18 years old, his/her Parent/Guardian, must also sign this form.

HOME CLUB
Chicago FSC registers you with US Figure Skating
Junior (under 18 yrs) $95
 Senior (18 yrs & older) $95
 2nd Family Member $45
Coach $95
Collegiate four-year membership $140
 Parent of CFSC Jr. Member $25
Introductory (First time member with US Figure Skating and CFSC)$30 / ASSOCIATE CLUB
You are a home club member of another club
Junior Associate $50
 Senior Associate $50
 2nd Family Associate $50
 Social $25
Coach, Associate $30

2016-2017 Dues - Make check payable to Chicago FSC

Mail Form& Check to: Sandy Culver, Membership Chair 236 East Ellis Ave., Libertyville, IL60048

Questions:Tel. 847-549-1385 E-mail: