ST. LOUIS METROPOLITAN SPEED SKATING CLUB, INC.
MEMBERSHIP APPLICATION
2004-2005
(Please fill out for all members of family)
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NAME: _______________________________________________________________
Last First Father (First) Mother (First)
Address:________________________________________________________________________
City: ________________________________________ State: ___ ZIP: ______________
PHONE: _________________________CELL PHONE: ________________________
E-MAIL ADDRESS: ____________________________________________________
$
$
$
Activity feE ($150)*
$
TOTAL AMOUNT DUE
$
* Activity fee of $150 is due if you didn’t participate in the 2004 Fair St. Louis fundraiser.
TOTAL AMOUNT DUE PAYABLE WITH THIS APPLICATION.
PLEASE MAKE CHECK PAYABLE TO: METROS SPEEDSKATING CLUB
Division (age as of July 1)
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Tiny Tot
5 and under
Pee
Wee
6-7
8-9
Midget
10-11
Juvenile
12-13
Junior
14-15
Intermediate
16-17
Senior
18-29
Master
30 and under
Skating Member – all rinks
$600
Skating Member – one rink (Webster,
Summit, Ice Zone)
$250
Skating Member – one rink (North
County)
$100
In consideration of the St. Louis Metropolitan Speed Skating Club, Inc. (“Metros”) accepting this membership(s), I (we), the
undersigned, do hereby for myself, my heirs, administrators, executors and assigns, waive and release any and all rights and
claims for damages I may have against Metros, it’s officers and member clubs and/or the owners of any property which may be
the site of any meets, practices, contests or other club events, agents, representatives, members, successors and/or assigns,
for any and all damages which may be sustained or suffered by me in connection with and/or arising out of my traveling to,
participating in, and returning from said contests or events.
Signature:
_____________________________________________________
______
Date:
___________
Metros Speedskating Club
409 Hibler Woods Ct.
St. Louis, MO 63141
(314) 434-7073
Pony
*(Parent or Guardian must sign if applicant is under 18 years of age)
Please return to: Harlan Kwiatek