ENTRY FORM

Return this portion with the seed times, waiver/release signed below, seed times, and announcer form, by Friday, January 16th.

Name:___________________________________________________________      ¡õ Male  ¡õ Female

Club:  ___________________________________  Association:_________________________________

Street Address:  _______________________________________________________________________

City:  ____________________________________  State:  ________________  Zip Code:  ___________

E-mail:  __________________________________  Phone:  ____________________________________

USS/SSC#:  _________________  Exp. Date:  _________  Birth Date:  _______Age as of 6-30-08:  ____

T-shirt Size:    Child M     Child L    Adult S    Adult M    Adult L  (Please circle)

Age Class Division:  __________________________

*SEED TIMES ARE REQUIRED*

Juvenile & Older ¨C 500m time__________, Midget & Pony ¨C 333m time_________& 500 m time_________

Pee Wee & Tiny Tot ¨C 200m time_____________ & 333m time _____________

(Please fill in as many of the seed times as possible to ensure accurate placement of skaters)

1st TIME COMPETITORS MAY SUBMIT SEED TIMES FROM A PRACTICE ICE SESSION

__________________________________________

If under 18 and a parent is not present, authorized adult to act on their behalf.

RELEASE FORM:  In consideration of acceptance of this application in the above program, I hereby waive, release

and discharge any and all claims for damages I may have against the Wisconsin Speed Skating Association, U.S.

Speed Skating, Cornerstone Community Ice Center, their assigned personnel involved in the program, or officers and

members for any and all liability arising out of or connected in any way with my participation in said program, even

though liability arises out of negligence on the part of the persons or entities mentioned above, or for any claim for lost

or stolen personal property of any description.  It is further understood and agreed that this waiver, release and

assumptions of risk is to be binding on my heirs and assigns.  Further, the undersigned agrees to the Code of Conduct

of U. S. Speed Skating, and will properly wear all required safety equipment.

__________________________           ____________________________                         _________________

Applicant¡¯s signature                    AND   Parent or guardian (if under 18)                              Date                     

CONSENT FOR MEDICAL TREATMENT:  I, the parent of _____________________________, (child¡¯s name)

if I cannot be contacted through reasonable efforts, hereby give permission to the officers of the Cornerstone

Community Center to call or drive my child to the physician, dentist, or hospital if a need for emergency treatment

exists.  An ambulance may be called if necessary.  I do hereby authorize the treatment by a licensed medical

physician, of my child in the event of a medical emergency, which in the opinion of the attending physician, may

endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed.

____________________________________          ____________                     

(Parent signature)                                                      (Date Signed)

ANNOUNCER¡¯S INFORMATION SHEET

Please return this form with the entry fee, seed times and waiver/release form to:Maria Karow, 2964 Sonoran Trl, Green Bay, WI 54313

Name:  ______________________________________________

Nicknames:  _________________________________________

Age:  _____________________    Male   Female (Please Circle)

Club:  __________________________________

Association:  ________________________________

School:  _________________________________

Grade:  ____________________________________

Favorite Music Group or Artist:  _______________

Favorite T.V. Show:  _________________________

Favorite Color:_____________________________ 

Favorite Kind of Cheese:_____________________

Other Activities & Interests:  _______________________

Favorite Distance to Race:  ____________________

Speedskating Heros:  _____________________________

Other People I Look Up to:  ________________________

Reason I Like to Speedskate:  ______________________

________________________________________________

Goals for this Season:  _____________________________

___________________________________

___________________________________

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