Please print clearly and fill out completely
Name: Dr.
      Last Name                                     First Name (and spouse)                                    Middle Initial

 Social Security number of person responsible for dues payments: ______________________________________
Home Address: ________________________________________________________________
Street                                                   City                                         State       Zip
 e-mail/fax numbers _______________________________________________________________
Home Phone: Member   (       ) _______________     Work Phone:   (       ) _______________
 Home Phone: Spouse:   (       ) _______________     Work Phone:   (       ) _______________
Children in Household and birth dates:
(List name on left and birth date on right)
(1)______________________    (1) ______________________
(2)______________________    (2) ______________________
(3)______________________    (3) ______________________
(4)______________________    (4) ______________________

 Check ICE SKATING Category desired and indicate if it is an Individual (I) or a Family Multiple (M).
_____ Basic With Tickets
_____ Light Use-Bronze (Up to 10 Sessions/Month
_____ Low Use-Silver (Up to 23 Sessions/Month)
_____ Standard Use-Gold (Up to 55 Sessions/Month)
______ (I) or ______ (M)
______ (I) or ______ (M)
______ (I) or ______ (M)
(An Intense User-Platinum Fee of $50/month will apply only if
more than 55 sessions are skated in a particular month or months)

 Names of family members who will be skating: __________________________________________

 Business, professions, skills, interests of adult applicant(s): _______________________________

Past association with SCW:
_____ Public Session
_____ Guest
_____ Hockey
_____ Summer School
_____ Public Lesson
_____ Other
 If applicable:
 Name of coach who will give private lessons: ___________________________________

Highest USFSA tests passed:
Figure: __________
Dance: ___________
Moves in the Field: _____________
Free Skating: ____________
Pairs: __________________

 Home Skating Club: _________________________     USFSA Number: ____________

      If you are transferring from another USFSA Club, please have a club officer or test chairperson send a letter indicating that you are a member in good standing at your home club.
      I (We) hereby apply for membership in SCW and have included the one-time $100 application fee, $125 Basic dues, plus the first month's payment of any skating privilege fees. 
      I (We) agree to comply with the rules and by-laws of the Club.
      I (We), understanding that ice skating is a dangerous sport, hereby waive any claims for damages sustained in the course of ice skating at the Skating Club of Wilmington.

Adult Signature: __________________________ Amount Enclosed: ________ Date: ____________