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Liberty Figure Skating Summer 2007!
Downloadable
(PDF) versions are on our Downloads
page.
Liberty
Summer Competition 2007 * Entry Form
BOTH
SIDES (PAGES) OF THIS FORM MUST BE FILLED OUT COMPLETELY
OR APPLICATION WILL NOT BE ACCEPTED!
Please
Print Neatly!
Competitor's
Name________________________________________Male/Female (circle
one)
Address__________________________________________________City_____________________
State/Province___________________Zip/Postal
Code____________Phone#(____)_____________
Email
address________________________________Date of Birth_______________________
Home
Club__________________________________________USFSA or CFSA#__________________
Name
of Coach______________________________________________Phone #_________________
Name
of Parent/Chaperone_____________________________________Phone #_________________
Cell#_________________
Name
of Partner_____________________________Partner's Home Club____________________________
(Each partner MUST complete seperate entry form)
Highest
Test Passed (as of 5/31/07): Free Skating________________ Pairs_________________
(Note: Skaters may "skate up" one test level.)
2006/2007
Qualifying Competition Record (if applicable) ___________________________________
State highest finish at Regionals (Final Rounds only) or higher.
PLEASE
CHECK ALL EVENTS YOU WISH TO ENTER:
FEES:
$105 for Senior through Juvenile events.
$80 for Pre-Juvenile and below events. (2 events=$130)
$50 for each additional event. (1 short and 1 long program = $155)
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Free
Skating.......................
1___Senior
Short Program
2___Senior Long Program
3___Junior Short Program
4___Junior Long Program
5___Novice Short Program
6___Novice Long Program
7___Intermed. Short Prog.
8___Intermed. Long Prog.
9___Juvenile
10___Pre-Juvenile
11___Preliminary
12___Pre-Preliminary
13___No-Test
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Compulsory
Moves......
14___Juvenile
15___Pre-Juvenile
16___Preliminary
17___Pre-Preliminary
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Pairs....................................
18___Senior
Short Program
19___Senior Long Program
20___Junior Short Program
21___Junior Long Program
22___Novice Short Program
23___Novice Long Program
24___Intermediate
25___Juvenile
26___Pre-Juvenile
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Total
# of Singles
Events Entered:_____
Total
# of Pairs
Events Entered:_____
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FEES:
$105 for Senior through Juvenile events. $80 for Pre-Juvenile
and Lower events. $50 for each additional event. (1 short
and 1 long program = $155)
-Pairs
skaters should split the fee (50% each). If a competitior
is skating in both Singles and pairs events, then the Singles
event will be considered the first event.
-Singles
skaters entering two singles short program events (at two
different levels) must pay the "first event" fee
for each short program entered.
Fees for
Singles Events_____________ Fees for Pairs Events__________
Total Entry Fees Enclosed_______________
MAKE
CHECKS PAYABLE TO: LIBERTY FSC
Send
to: Liberty FSC, P.O. Box 4019, Philadelphia, PA 19118
Payment
MUST accompany application. There will be a $30.00 charge
for all NSF checks.
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Certification
of Competitor by Home Club Official (Required)
I hereby
approve the entry of the skater named on this application
and certify that he/she is eligible to compete in accordance
within the rules of the USFSA, and that the entrant is a member
in good standing of the Home Club.
SIGNED______________________________TITLE____________________DATE_______________
Home Club_____________________________________________
Telephone#__________________________
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Certification
by Athlete and Parent/Guardian (Required)
Athlete:
I agree to conduct myself, both on and off the ice, in a
manner that will reflect favorably upon this competition
and upon the sport of figure skating, and that is consistent
with the high standards of the sport. I agree to respect
the person and property of others.
Athlete/Parent/Guardian:
I understand that the USFSA and the clubs or organizers
of competitions undertake no responsibility for damages
or injuries, or loss of property suffered by the skaters
or officials. As a condition of and in consideration of
the acceptance of their entries or participation therein,
all entrants, their parents and guardians and officials
shall be deemed to agree to assume all risks of injury to
their person and property resulting from, caused by or connected
with, the conduct and management of the competition, and
to waive and release any and all claims which they may have
against any officials, the USFSA, the club hosting the competition,
and against its Officers, and their entries shall be accepted
only on such condition.
Athlete's
Signature_______________________________________ Date_________________
(SIGNATURE REQUIRED)
Parent/Guardian's
Signature________________________________Date_________________
(SIGNATURE REQUIRED if athlete is under age 18)
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Authorization
for Emergency Medical Treatment (Required)
In
the event I am unavailable, I hereby give permission for
any emergency medical diagnosis,
treatment or procedure for:_________________________________(print
skater's name)
Emergency
medical information (allergies, pre=existing conditions,
medications, etc.):
Name
of Physician_______________________ Telephone #__________________
Name
of insurance Company_____________________________________
Policy
number___________________________Name of Insured_______________
Signed_________________________________
Date________________
(SIGNATURE REQUIRED)
Relationship
to Skater_____________________ Telephone #__________________
(SIGNATURE REQUIRED by Parent/Guardian if athlete is
under age 18)
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Send
fully completed Form and Payment to:
Liberty
Summer Competition
P.O. Box 4019
Philadelphia, PA 19118
*ENTRIES
MUST BE POSTMARKED NO LATER THAN MAY 25th, 2007*
The
Local Organizing Committee reserves the right to limit entries.
Mail Early!
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