Membership Application Form (Print)

Use this application to pay by check or money order. To pay by credit card instead, use our credit card order form.

Title: Mr/Ms/____ First Name:__________________ Last Name:_____________________
Street Address:__________________________________________________ Apt: ________
City:_____________________________________ State:________ Zip:_________-_______
Home Phone: (______)__________________ Work Phone: (______)___________________
Occupation:_____________________________ Company:______________________________
Date of Birth:___/___/___ Gender (M/F):___ Email:______________________________
Level: [ ] beginner   [ ] rec/intermediate   [ ] advanced   [ ] pro/elite
How did you hear about us? ____________________________________________________

If you are renewing your membership, what is your current membership
number? ____

The club is run entirely by our members who volunteer their time and skills to help out. By volunteering you'll meet other members while also providing a valuable service to the club. Please let us know how you can help.

I would like to volunteer to help with:

  [ ] mailings        [ ] sponsor relations
  [ ] marketing       [ ] writing for the newsletter
  [ ] copy writing    [ ] organizing or marshaling a group skate
  [ ] other __________________________________________________________________

Basic membership . . . . . . . . . . . . . . . . . . . . . . .  $25.00 _______

Family membership . . . . . . . . . . . . . . . . . . . . . . . $35.00 _______
(Note: Family membership does NOT extend to Empire Speed membership.)

Empire Speed membership . . . . . . . . . . . . . . . . . . . . $35.00 _______
(Note: Empire Speed membership includes Empire Skate Club membership.)
   Racing team affiliation (if any): ______________________
   Best 10K time (i.e. one Central Park loop): ____________

T-shirt:___(S/M/L/XL)  Design: I [Skate] NY  $15.00/ea. _______


TOTAL ENCLOSED . . . . . . . . . . . . . . . . . . . . . . . . . . . .$_______


WAIVER/RELEASE: I hereby agree to NOT SUE, AND HEREBY WAIVE, RELEASE AND DISCHARGE the Empire Skate Club, and their affiliates and subsidiaries (including but not limited to Empire Speed) and their respective officers, directors, employees, volunteers, agents, assigns, representatives and independent contractors (the "Releasees") from any and all claims or liability whatsoever on account of death and/or damages to person or property and/or injuries I or my property sustain as a result of my participation in Releasees' programs or events, notwithstanding that same may have been caused by the NEGLIGENCE of any of the aforesaid or otherwise. I accept full responsibility for any and all such damage and/or injury which may result.

I hereby agree to participate in these programs and events in accordance with the foregoing Release. I hereby acknowledge that I have been advised by the Empire Skate Club that protective gear (including but not limited to wrist guards and ANSI-certified helmet) must be worn at all times while I participate in an Empire Skate Club skating program or event and that failure to do so is at my sole and absolute risk.


Dated this _____ day of ___________________, of 20_____.

___________________________________ ___________________________________
Participant's Signature
Parent/Guardian's Signature
(if Participant is under 18 years old)

Mail completed form, along with a check made out to Empire Skate Club of New York, to:
Membership Application
Empire Skate Club of New York
Post Office Box 20070, London Terrace Station
New York, N.Y. 10011
Because we're committed to protecting our members' privacy, we will never reveal any of the information on this form or sell it to outside companies. Our mailing list is used exclusively for club-related announcements.

If you have questions about membership, email our membership coordinator at membership@empireskate.org.