Masters Gold Silver Bronze PreBronze Masters Adult Young Adult

ADULT OPEN COMPETITION « The Mountain Cup » VILLARD-DE-LANS
2-4 June 2011
ENTRY FORM
Partners must complete separate entry forms
First Name/Last Name
USFSA#
CFSA#
NISA#
other
Address
City
State/Zip code
e-mail or fax n°
Age on 2/06/2011
Date of birth
Home club
Name of partner
Partner’s e-mail
or fax n°
Sex:
F
M
Highest test passed (please look up « comparative table » enclosed):
USFSA Adult
ISU/ISI
Other :
Free Skating:
Free Skating:
Free Skating:
Dance:
Dance:
Dance:
Pair:
Pair:
Pair:
Please check off age class and sex:
( ) 18-20
( ) 21-28
( ) 29-35
( ) 36-45
( ) 46-55
( ) 56 and +
( )M
( )F
Please check off event(s) you wish to enter:
Free skating
Masters Gold Silver Bronze PreBronze
Interpretative Skating
Masters Adult Young Adult
Interpretative program(couple) (partner’s name :…………….)
1 woman /1 man 2 women 2 men
Pairs (nom du partenaire :…………….)
Masters Adult Gold Adult Silver Adult Bronze
Couple (Ice Dancing Compulsory) (partner’s name :…………….)
Masters Gold
Pregold
Vermeil
Silver
Bronze
PreBronze
Preparatory
Preliminary
Solo Ice Dancing Compulsory
Gold Pregold Vermeil Silver Bronze PreBronze Preparatory Preliminary
Couple (Free dance) (partner’s name :…………….)
Masters
Gold
Silver
Bronze
Couple (Short dance) (partner’s name :…………….)
Gold
Danse interprétation solo
Gold Silver Bronze PreBronze
Improvisation
Masters Adult Or Adult Silver Adult Bronze
Compulsory Figures
Masters Gold Silver Bronze PreBronze Open
Entry Fees:
60 EURO First Singles Event per person
30 EURO Second Singles Event per person
35 EURO Each Partner of Pair or Dance Team (1st event)
30 EURO Each Partner of Pair or Dance Team (2nd event)
25 EURO Each Partner of Pair or Dance Team (3rd event)
35 EURO Figures Event
285 euros per Team for Synchronized Skating
A Complete Entry Will Contain the Following: ___ Entry Form (completed)
___ Proof of Age
___ Copy of test certificate
___ Entry Fees
___ Practice Ice Application
There is no need to send a proof of age if you have already competed in a Mountain Cup
competition and no need to send a test certificate unless you have tested recently.
• Make your money transfer directly with PAYPAL to the e-mail : [email protected]
• or make a money order payable for EURO ……..
Make the money order payable to:
RELEVE D'IDENTITE BANCAIRE
PARTIE RESERVEE AU DESTINATAIRE DU RELEVE
Ce relevé est destiné à être remis, sur leur demande à vos créanciers ou débiteurs appelés à
faire inscrire des opérations à votre compte (virements, prélèvements, etc.). Son utilisation
vous garantit le bon enregistrement des opérations en cause et vous évite ainsi des
réclamations pour erreurs ou retards d'imputation.
Banque Indicatif Numéro de compte Clé RIB
30002
02639
0000079076V
63
Domiciliation
CL VILLARD DE LANS (02639)
IDENTIFICATION INTERNATIONALE :
IBAN
FR46 3000 2026 3900 0007 9076 V63
Code B.I.C.
CRLYFRPP
TITULAIRE DU COMPTE : GLACES & CO
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DEADLINE : April 4th , 2011
CERTIFICATION BY CLUB OFFICER
I hereby approve the entry of this skater and certify that he/she is a Member of the Club in good
standing, is eligible to compete in the events entered and is an eligible skater in accordance with the
current USFSA Rulebook.
Signature of Club Officer
Title
Print Name
Home Club
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Accidents and Liability
The Patinoire Villard-de-Lans and the Organizers undertake no responsibility for damages or
injuries suffered by skaters or officials. As a condition of and in consideration of the acceptance of
entries of participation, all entrants, family members, coaches 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 or management of the competition. Entries will be accepted only under such
condition.
Signature of competitor: