""WICHITA CAROL FOX ICE DANCE AND FIELD MOVES CLINIC REGISTRATION FORM ""

Advanced reservations would be appreciated. Please, make checks payable to the Wichita FSC. Mail registrations to - Robert Boroughs 1926 Keith Ct., Wichita, Ks 67212. All Sales taxes are included.

Name:___________________________________________________________________________

Address:__________________________________________________________________________

City:_____________________________State:____________________________Zip:____________

Daytime Phone:______________________________________________________

Evening Phone:______________________________________________________

Email:______________________________________________________________

Skating level you are comfortable at:______________________________________

Pro affiliation:______________________________________________________

Full weekend ........................................................................ $100.00 __________
*OR*
Saturday First Session ............................................................. $50.00 __________
Saturday Second Session .................................................... $50.00 __________
Saturday Third Session ................................................. $50.00 __________
Sunday First Session ...................................................... $50.00 __________
Sunday Second Session ........................................................ $50.00 __________
Total ......................................................................................... $ __________


The undersigned agrees to hold harmless Robert Boroughs, the United States Figure Skating, the Wichita Figure Skating Club and all of its officers, board members, volunteers and agents and the Wichita Ice Center, its owners, employees and agents, and the City of Wichita, its employees and agents, from any loss, damage and/or injury that may be sustained in any manner by the applicant while participating in any activities of the Wichita Ice Dance Weekend. In case of injury, I hereby authorize first-aid treatment for the applicant while participating in said dance weekend.


_______________________________________________ ______________
Skater's Signature Date
(parent or guardian if skater is under 18 years of age)