London Track 3 Instructor Registration

Student Registration

Required Fields are marked with an asterisk (*).

Personal Information

First Name:*

Last Name:*

Date of Birth:*

Height:* ft. in.

Weight:* lbs.

Gender:* Male Female

Student Contact Information

Address:*

Address (2):

City:*

Province/State:*

Country:*

Postal/Zip Code:*

Main Phone:* - -

Work Phone: - -

Email:*

Parent/Guardian Contact Details (if under 18 years of age)

Parent/Guardian Name:*

Relationship:

Same Contact Information as Student

Address:*

Address (2):

City:*

Province/State:*

Country:*

Postal/Zip Code:*

Contact Phone:* - -

Alt. Phone: - -

Email:

Emergency Contact Details

Contact Name:*

Relationship:

Same Contact Information as Student

Address:*

Address (2):

City:*

Province/State:*

Country:*

Postal/Zip Code:*

Contact Phone:* - -

Alt. Phone: - -

Email:

Skier Information

Ski Experience? No Yes yrs.

Have you skied with Track 3 before? No Yes

Are you currently enrolled with Special Olympics Ontario? No Yes

Are you interested in participating in our Special Olympics London Program on Mondays? No Yes

Equipment

Do you own your own:

Boots: No Yes

Skis: No Yes

Poles: No Yes

Outriggers: No Yes

Applicant will attend equipment fitting on September 17th, 2011 between 9:00AM and 12:00PM. Equipment fitting is mandatory before getting on the hill. Those who do not attend this session will likely lose a night of instruction in order to have equipment fitting done, however will be able to participate in the program. Approved ski helmets are mandatory

Preferred Session

Preferred Time:*

Second Choice:

If you would like your instructor from last year, please list the name of your instructor(s) below.
If you wish to have a new instructor or if it is not a major concern as to who your instructor will be please also indicate below:

Please Note:
** We will try our best to accommodate the above request, however all student/instructor pairings are made to insure that students are matched with instructors to best meet their individual needs and that these pairings are at the mercy of instructor availability.*

Health Information/History

Student's Health Card Number: (for emergency purposes)

Disability Information:

Allergies:
(food, environmental, drugs, etc.)

Medication: No Yes If Yes, list type and time of administration

Does the applicant have seizures? No Yes If Yes, what type?

Frequency, duration and warning signs:

Does the applicant have a shunt? No Yes If Yes, what type?

Describe symptoms of shunt blockage:

Does the applicant have any special toileting needs?

Does the student react strongly whether positively or negatively to any situation? No Yes If Yes, please give examples

Please give suggestions how the instructor could best deal with them.

Select Payment Option

Mandatory:
WAIVER OF LIABILITY TO BE SIGNED BY A PARENT / GUARDIAN OR A SUBSTITUTE DECISION MAKER AND WITNESSED BEFORE A TRACK 3 DESIGNATED REPRESENTATIVE PRIOR TO THE COMMENCEMENT OF ON HILL ACTIVITIES.

CONSENT TO USE PHOTOGRAPHS, MOVING PICTURES, TELEVISION AND SOUND RECORDINGS

I hereby agree that any photographs, moving pictures, television and sound recordings of myself taken by the participants or agents of the London Track 3 Ski School, may be used by the London Track 3 Ski School for education, training and or publicity purposes.

Program Fee: $150.00

Select a form of payment:*

Cash or Cheque

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