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2006 ICE HOUSE ADULT CAMP
REGISTRATION
Please Print
Name of Skater:
___________________________________________ USFSA (ISI)#
__________________________
Address: _______________________________________City:
________________ State: _________ Zip: __________
Home Club: _________________________________ Phone (H):
_________________ (W): ____________________
(Circle one) Competitive
Singles Recreational
Singles
Pairs Dance
Highest Test Passed: _______________________________
I/we compete at the: _________________________level.
Most Difficult Jump(s) Landed Consistently:
______________________________________________________________________________________________
Highest Moves Test passed:
______________________________________________________________________________________________
Dance/Pairs:
____________________________________________ Partner
name: __________________________
(Pairs
skater MUST Have a partner)
The
skater hereby waives all claims for injury and/or damage or
loss of property arising from or during the training camp
and therefore hold harmless all personnel associated with
this training camp, the USFSA, the American Academy Figure
Skating Club, the Ice House and Midtown Bridge, LLC.
_____________________________________________________
______________________________
SIGNATURE OF SKATER
DATE 

FORM OF
PAYMENT
AMOUNT: _______________________________________ CHECK:
# __________________________
CREDIT CARD: #
________________________________________________ EXP.
DATE: _________
  
FORM OF PAYMENT
AMOUNT:_________________________CHECK:___________________
Total Due:
CREDIT CARD
#:___________________________Exp_______________
$________
NAME AS IT APPEARS ON THE CARD:
_________________________________________________________________
·
Liability Waiver MUST be signed *
Registration Deadline: Postmarked by June 5, 2006
-
No Refunds for ANY REASON, including injury or
illness after June 5, 2006. Refunds Prior to this
day will be considered with a doctor’s note.
Mail completed registration form to: Craig
Maurizi, Ice House, Phone: (201)
487-8444 Ext. 205
111 Midtown Bridge Approach
Fax: (201) 498-1250
Hackensack, NJ 07601
e-mail:
cmaurizi@icehousenj.com
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