PLEASE PRINT.

Name:______________________________________________     Age on June 30, 2000:______________

Address:____________________________________________    Birthday:__________________________

City:________________________________________  State:______    Zip:______________

Phone:(_____)_____________________     e-mail:____________________________________    M:________

USFSA#____________  Home Club:________________________________________________     F:_______

Highest Tests Passed: F.S.____________________________Moves:_______________________________

      Coach's Name:________________________________________    Coach's Phone:_________________