fiche individuelle d`inscription

REGISTRATION FORM –AS SKEMA
First name
Last name
Date of birth
Male / Female
Phone number
E-mail
Postal address
Postcode + City
Program
Year of studies
Sport(s)
Licence Number
Subscription fee 35€ : payment by cheque made out to « Association Sportive SKEMA» Yes
Medical Certificate
I, the undersigned, Doctor
__________________________
Hereby certify , / having examined
Ms or Mr (Last Name & F Name)
____________________________________________
Date of birth __/__/____,
that there is no medical reason why the student should
not do physical education or sport including at
competition level.
___________________________________________
___________________________________________
___________________________________________
Date : _________________
No
I, the undersigned, hereby declare that :
- I am regularly registered in the the higher education institution mentioned above
- I have read the FF Sport U rules and regulations and I adhere to
- I have handed to the registrar’s office a medical that proves I am not advised against
practicing sports and sports competition
- I have been informed by my FF Sport U Club of the interest of taking out a personal
insurance policy covering bodily injury to which sport can expose me
- I authorize the SKEMA Business School’s Sport Association, without charge, to
photograph/ film me and to use my image in all types of media for courses and sport
competitions. I understand that this will be done exclusively in connection with the
internal and external communication for the Sport Association.
- You have a first level of security-insurance,(description on knowledge) through your
sports association. In this case, IA Sports + MAIF offers you the opportunity to
effectively complete your protection.
With AI Sports + MAIF, you can count on stronger body insurance against all accidents
that might occur during your sports: high ceilings compensation, assistance services at
home.
You find on the back of this sheet, a notice containing the information about the
contents of the guarantee IA + Sport, pricing and subscription terms. It operates under
the terms of the contract Raqvam Associations & Collectivités agreed by the
association and replaces the guarantee compensation for bodily injury eventually
acquired under it.
-I.A. Sport + covers you in case of bodily injury arising during the activities implemented
by the community named above. Trips to get to the location of these activities and in
return are also guaranteed. It is acquired in the entire world.
-The warranty is acquired after the receipt of your subscription request by the MAIF.
Unless special request of the association, it is acquired until August 31, 2016, end date
of the sports season (and in the limit of maximum 12 months).
-Whether or not you subscribe IA Sport + warranty, complete the slip (back) and give it
back to the head of the Sport Association, with, where appropriate, the payment of the
corresponding additional levy (the collection of contributions will be made by the
association, no payment should be addressed directly to the MAIF).
Date
Signature preceded by the words "read and approved"
Stamp and signature :
I do not authorise AS SKEMA to transmit my contact details to its partners
The information collected in this document is required to process your membership. According to the Law 78-17 of 06/01/1978, you may request at any time that the
information contained in any file used by the Company, its agents, reinsurers, and professional organizations and those used by intermediaries be communicated to you
and corrected if necessary. . This right may be exercised by your club.
AS SKEMA Sophia Antipolis -Paris
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With your fee, you have a basic insurance guarantee, conditions online
http://knowledge.skema.edu/courses/ASSOCIATIONSPORTIVES/?id_session=0
If you want an additional insurance / filled the form p 4 and deposit at the sport office n° 271 or 257.
AS SKEMA Sophia Antipolis -Paris
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AS SKEMA Sophia Antipolis -Paris
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AS SKEMA Sophia Antipolis -Paris
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