NAME: _______________________________________________________ SEASON:____2012-2013____
CLINIC(S) I WILL BE TAKING:
BILLING ADDRESS:
CITY: STATE: ZIP:
DAYTIME PHONE: EVENING PHONE: FAX:
EMAIL:
CLUB AFFILIATION: ______________________________________________________________________
PAYMENT ENCLOSED: $ CHECK #______________________ or
CC#__________________________________________________ EXP DATE:
3 digit security code________
I have read the materials requirements and will come prepared with the appropriate study guide(s) and the USSA rule book or Chapter 8 of the USSA guide.
Signature_________________________________________Date___________