Please provide the following contact information:

Name
Club
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Home Phone
E-mail
Date of Birth	MMDD19YY
Classification	& Year: Example "D99" F E S
Events Entering	U14MF   U14ME    U14MS
Events Entering	U14WF   U14WE    U14WS
Events Entering	U16MF   U16ME    U16MS
Events Entering	U16WF   U16WE    U16WS
Events Entering	U19TMF   U19TME    U19TMS
Events Entering	U19TWF   U19TWE    U19TWS
Events Entering	MF   ME  MS
Events Entering	WF  WE  WS
Events Entering	TMF  TME  TMS
Events Entering	TWF  TWE  TWS
Registration Fee (Includes first event)                   $40.00
Additional Fees Add $20 for each additional event $
Total due on arrival at venue                              $

By submitting this form you are agreeing to submit payment if you fail to notify the secretary of the division before the event that you will be unable to attend.