MITEY MITE SKI TEAM

2010 ENROLLMENT FORM

Athlete Information (please print)

First Name_____________________________________ _______

Last Name ________________________ _______

Sex Date of Birth

School _____________________________ Grade_______

Mailing Address ________________________

City__________________________ Zip_____________________

Home Phone_____________________________________________________________

Work Phone(s)___________________________________________________________

E-mail Address ___________________________________________________________

Heads of Household _______________________________________________________

(First and last names of both parents or guardians where the athlete resides)

Home Address ___________________________________________________________

City__________________________ Zip_____________________

Have you completed and signed the attached Medical Release? __________________

ENROLLMENT FEES (Please make check payable to Juneau Ski Club)

2010 Mitey Mite Program (per athlete)……..………. $200
(Includes $20 JSC Family Membership)

Please send forms and payment to:

Juneau Ski Club Mitey Mites
9356 Turn St
Juneau AK 99801
If you are planning on enrolling on January 9th, 2010 please call 789-5761 so we know you are coming.
Enrollment Form and Payment Due on or before January 9, 2010.
For more information call Mike Satre at 789-5761.

This activity partially funded by the Citizens of the City and Borough of Juneau, Alaska.
 Mitey Mite Ski Team
2010 Medical Release Form
January 9, 2010 to March 14, 2010

Please read and sign.

Statement of Risk: I, __________________________________ understand that alpine skiing carries significant risks
of personal injury. I know there are natural and manmade obstacles or hazards, surface and environmental conditions
and risks which in combination with a racer’s actions could cause severe or occasionally fatal injuries. In participating
in the Juneau Ski Club programs and skiing at Eaglecrest, such dangers are recognized and accepted whether they are
marked or unmarked. I hereby release and hold harmless Eaglecrest Ski Area and it’s employees, the Juneau Ski Club,
it’s coaches, race officials, USSA, USSA Alaska Division and any person connected with the above program during
participation in any Juneau Ski Club activity, including but not limited to training, racing, work parties, social events,
use of Eaglecrest Ski Area and Juneau Ski Club facilities or equipment, team travel, or any social events associated
with the Juneau Ski Club programs.

Release Authorization for Medical Attention

I hereby grant permission for a doctor to perform any diagnostic, anesthetic, operation, or curative remedial procedure
they deem necessary or advisable for the care and treatment of the above named skier.

Enrollment of Named Athlete

By signing below, I hereby agree to enroll the athlete named above with the Juneau Ski Club, and agree to pay all
membership dues and program fees for named athlete by January 9, 2010.

Please Read the Above Information before Signing

Signature of Child Date Signature of Parent or Guardian Date

Residence Address

Mailing Address

Phone Numbers

Personal Physician

Medication (if any)

Medical History

Medical Insurance Co.

Policy Number

Insurance Company Phone #

Enrollment Form, Medical Release & Payment Due on or Before January 9, 2010.
This activity is partially funded by the Citizens of the City and Borough of Juneau.