MEDIA RELEASE, CONSENT TO USE/DISCLOSE PERSONAL INFORMATION, LIABILITY WAIVER

Skaters Name: _____________________________________

There are opportunities throughout the year when skaters are photographed, interviewed or videotaped during public events and Skate Brockville would like to share these on the club website or Facebook page, and through media release to the newspaper, radio, or television.  Photos and names can only be displayed with the permission and knowledge of the parent/guardian and will not be used for commercial gain. I consent to my child’s photograph, interview, videotape, name/accomplishment being used on the Skate Brockville website and/or Facebook page, used for media releases, or public television, radio, or newspapers. _____ Initals

Skate Brockville and its agents respect everyone’s privacy and will work diligently to ensure that all personal information provided by Skate Brockville remains accurate, confidential, and secure. We treat all information with respect and discretion.

I consent to my child’s name, address, email address, telephone number, sex, age, date of birth, Skate Canada number, skating level, and any other additional information on required by the club for the following purposes: sending and receiving communications to and from Skate Canada, determining eligibility, in case of emergencies, and/or organizing and preparing for competition, test days, and annual ice shows. _____ Initals

I agree that all participants/family hereby waive all claims for injury and/or damage or loss of property arising from or due to training at Skate Brockville and hold harmless all personnel associated with Skate Brockville. I understand that any member whose account is past due will not be permitted to try and test or enter any competitions and will not be allowed to skate until the account is settled.

Name of parent/guardian: _____________________________________

Signature of parent/guardian: __________________________________