""2012 WICHITA ICE DANCE WEEKEND 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

Name:___________________________________________________________________________

Address:__________________________________________________________________________

City:_____________________________State:____________________________Zip:____________

Daytime Phone:______________________________________________________

Evening Phone:______________________________________________________

Email:______________________________________________________________

Dance level you are comfortable at:______________________________________

Pro affiliation:______________________________________________________

Full weekend ........................................................................ $145.00 __________
*OR*
Friday Night Session ............................................................. $40.00 __________
Saturday Morning Session .................................................... $50.00 __________
Saturday Afternoon Session ................................................. $50.00 __________
Sunday Morning Session ...................................................... $55.00 __________
Saturday Dinner Dance ........................................................ $50.00 __________
Total ......................................................................................... $ __________

Since the hotel needs to order food in advance, an RSVP would be appreciated.
To attend the Dinner/Dance, please respond by Monday April 30, 2012.

Check here if you plan to attend the Dinner/Dance
__________

The undersigned agrees to hold 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)