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Pepsi Ice Midwest & Fitness Center Skating School
- Application - 913 851-1600 fax
814-3754
12140 W 135th St. Overland Park, KS 66221
Name:
____________________________________ Age: _____ DOB
___________________
Address:
________________________________City_________ State______
Zip__________
Home Phone___________________ Work
Phone_______________ Parent
_______________
Class____________________ Day ________
Time________ E-mail_____________________
NOTE: Registration only
accepted with payment.
Credit Card #
________________________________ Exp___________
Name:
____________________________________________________
Pepsi
Ice Midwest & Fitness Center Liability Waiver
By having
registered the above person I lessons I, as parent or guardian
of participant, agree to allow the individual named herein to
participate in the aforemenmtioned activity (ies), and I
further agree to indemnify, and hold the Pepsi Ice Midwest
& Fitness Center, skating school director, and instructors
harmless from and against any and all liability for any injury
or loss of property by the aforementioned individual(s)
arising out of , or in any way connected with, his/her
participation in this activity.
_______________________________________
____________________
Parent/ Guardian
or Participant Signature Date
Check out
our ad in the Southwestern Bell Yellow Pages or visit
www.pepsiicemidwest.com
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