Illinois Fencers Club

Membership Application Form

Please fill in all of the following information:

First Name: _____________   Middle: _____________   Last: ____________________

Date of Birth: __________________

Street Address: _________________________________________________________

City: ___________________________   State: _________   Zip: _________

Home Phone: (______) ______________   Work Phone: (______) ______________

E-Mail: _______________________ Cell Phone: ___________________________

Start Date: __________________   Dues: $_______, payable to “Illinois Fencers Club”

Emergency Contact & Phone No.: __________________________________________

PLEASE NOTE:

1. Club individual equipment (masks, jackets, foils, etc.) must remain at the club, so it is available for all to use.  Return it to the cabinet after use – do not take it home or a fee may be imposed.  Please treat the Club’s scoring equipment (reels, machines, etc.) carefully, because it is very expensive to replace.
2. Like any other sport, fencing has a few key safety rules that must be observed at all times.  These include:

· Inspect equipment (mask, jacket, foil, etc.) for safety before use.

· No fencing, practicing, demonstrating, etc. with blades unless BOTH persons are wearing MASKS and other protective gear and you have the permission of the instructor.

· No fencing or practicing without a fencing jacket, pants, mask and a glove.

· Fence at a controlled pace, maintaining your balance at all times.

WAIVER OF LIABILITY

I understand that participation in any athletic sport, including fencing involves a possible risk of injury.  I voluntarily recognize, accept, and assume this risk, and I release the Illinois Fencers Club, its officers, instructors, members and agents, and the Mount Prospect Park District from any liability arising from any injury I, or my child, may sustain.

Signature: _____________________________________   Date: _______

Signature of Parent/ Guardian: _____________________ Date: ________
(If fencer is under the age of 18)

For your own safety, do you have any medical conditions in which the Illinois Fencers Club should be made aware? Y/N Please list any preexisting conditions: (asthma/ diabetes/ epilepsy/ hypertension, etc.)
_________________________________________________________________________________

How did you hear about the Illinois Fencers Club? Circle: Park District Brochure/ Park District Web Site/
IFC Web Site/ IFC Literature/ Other: _________________________________________