Music
City
Figure Skating Club
July
1, 2007-
June 30,
2008
Member
Name:________________________________
__USFS#________________
(if applicable)
Address______________________________________________________
City,
State, Zip
Email
address _______________________________________________________________
Home
Phone (_____) ________________
Cell Phone(_____)___________________
Date
of Birth___/___/______
Female / Male
US Citizen
Yes / No
circle
circle
Coach
of Record ______________________________
Skating
Level_____________________
(if
applicable)
Membership
status (circle one) :
Home club Member
Non Home Club Member
Member
of another skating club (specify) ____________________ or individual member of
USFS
Home
Rink:
Centennial Southern
Ice
Other(specify)__________________
Circle
one
Primary
Activity :
Parent/Guardian,
Coach,
Competitive Skater, Recreational Skater
Other_______________
Circle
others that apply :
Adult Skater Synchro Collegiate Competitive
Skater
Recreational skater
Test
Skater USFA
official/ officer
Coach
Parent/ Guardian Club
Officer/Board Member
Volunteer
Circle
one
Parent
(if under 18 years old) __________________________________
Work
Phone (_____) ________________ Cell Phone(_____)_______________
Parent
(if under 18 years old):__________________________________
Work
Phone (_____) ________________ Cell Phone(_____)_______________
Additional
Family Members (list)
name
date of birth
name
date of birth
name
date of birth
name
date of birth
Emergency
Contact: Name________________________
Home
Phone (____)__________________
Work
Phone (_____) _______________
Keep
the following information confidential ( i.e. do not publish in MCFSC
Directory)
Circle all the apply
Home address Home phone Work
Address
Email Address
Please make checks payable to the Music City Figure Skating
Club.
Mail to : Music City Figure Skating Club
c/o Carrie Moeller
184
Forest Trail Drive
Brentwood,
TN 37027
See
below for membership fees
Total
Amount Included $______________
Home Club
Member
Non-home Club member
First Member in household
$80.00
$55.00
Each additional member
$37.00
$30.00
(non-parent)
Parent Member
$27.00
$25.00
Note: Non- home club membership does
NOT include USFS membership.
