Club Name: _____________________________________________

Club Address: ___________________________________________

City: _________________________State____________Zip_______

Phone: ( ) - _______________ E-mail/Fax: __________________

Coach: ________________________________USAG #___________ Safety Cert. Exp. _______

Coach: ________________________________USAG #___________ Safety Cert. Exp. _______

Coach: ________________________________USAG #___________ Safety Cert. Exp. _______

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Form Completed by _________________________________ (Please check) Team Comp. Lvl. 4 __, Lvl. 5 __, Lvl. 6 __