2019 Show Registration Form

SHOW REGISTRATION

Event Date: June 22, 2019
SKATER INFORMATION:
Skater's Name*

First NameLast Name
Is skater under the age of 18?*

YesNo
Parent/Guardian Name*

First NameLast Name
Skater's Gender*
Birth Date*

MonthDayYear
Age*
Height*
SKATING BACKGROUND:
Primary Rink*

Chiller DublinChiller EastonChiller NorthNTPRD ChillerOther
Skater is currently taking....*

Group lessons ONLYPrivate lessons ONLYBoth group and private lessonsn/a
Current group lesson instructor
Current class name/level
Private lesson coach*
Skating Category*

Basic SkillsFree SkateFreestyleMoves in the Field
Highest Basic Skills Level Passed*
Highest Free Skate Level Passed*
Highest Freestyle Level Passed*
Favorite Jump
Jump Rotation Direction*

CounterclockwiseClockwise
Favorite Spin
Favorite Artistic Element
Highest Moves in the Field Level Passed*
CONTACT INFORMATION:
E-mail (required for all event communications)*
Preferred Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT*

First NameLast Name
Emergency Contact Phone #*
Relationship to Skater*
PAYMENT:

Registration Fee*

Registration$150.00

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

SHOW REGISTRATION