PRE-REGISTRATION FOR SHANNON HEIGHTS SKATING CLUB  WINTER SESSION 2004/05

Skater’s Name: _________________________________

Address: ________________________________________

                _________________________________________

Email Address:______________________________________

Postal Code: ____________ Phone Number:____________

Date Of Birth: ____________    Sex: F or M

Health Card No.___________________________

Skate Canada No. _________________________

Test Passed

Dance:                                          Are you a member of The Military ________

Skill: ___________________     Spouse ____ Dependant   ____ Other  ____

Free:___________________     None of the Above ______

Interpretive: _____________ _______

I understand that my son/daughter will be registered as home club Shannon Heights unless I inform the executive otherwise prior to July 1^st 2004. Please mail  form before June 15^th.

Pre-registration is $25.00 per skater. ( Which is non-refundable)

Signature:_____________________________________

Please mail form to:  Kim LeBlanc

                                   21 Connolly Rd

                                   Lwr. Sackville, NS

                                   B4E 1S6