Skatebowl Waiver Form

Skater Information

Name

First Name *

Last Name *

Date of birth *

Day *

Month *

Year *

Address

Address 1 *

Address 2

City *

Postal Code *

Daytime telephone no. *

Email address *

Medical History

Have you a history or receive medication for any of the following:

 Select as approppriate

Asthma

Diabetes

Epliepsy

Stroke / Heart Attack

More info on the above or other medical conditions not listed

Emergency Contact

Name

First Name *

Last Name

Phone Number *

Declaration

I confirm that I have received and read a copy of the Skating Rules and Terms and Conditions and fully understand and agree to them.

Select date *

Day *

Month *

Year *

For skaters under the age of 16

I am the Parent / Guardian of the member and I confirm that I have received and read a copy of the Skating Rules and Terms and Conditions and I fully understand and agree to them on the member's behalf.

Select Date

Day

Month

Year

Relationship

Parent

Legal Guardian

Name

First Name

Last Name

Address (if different from above)

Address 1

Address 2

City

Postal Code