Vitaly Scherbo Invitational Entry Form

Men's Levels 4 - Elite

Women’s Levels 4 - Elite

January 17th - 19th, 2009

Felicia Boudreau, Meet Coordinator    e-mail: felicia@vssg.lvcoxmail.com    

Website: www.vssg.net   Phone: (702) 259-5020         Fax: (702) 645-9173

Registration Deadline: December 1st, 2008 for US entries

November 1st, 2008 for all foreign entries

 

Team Name: ______________________________ USAG Club #: ___________________

Address: ________________________________________________________________

City: ______________________ State: _____ Zip: ________ Phone #:______________

Fax#: _____________________ E Mail Address: ________________________________

Coach’s Name: _______________________    Coach’s Name: ______________________

USAG Pro Member #: __________________    USAG Pro Member #: _________________

Pro Member Exp. Date: _________________   Pro Member Exp. Date: _______________

Safety Certification Exp. Date: ___________  Safety Certification Exp. Date: __________

 

	FIRST NAME	LAST NAME	USAG #	LEVEL	BIRTH DATE	US CITIZEN?
exp.	Sally	Smith	123456	4	01/11/2000	Y           N
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All fees must                 Mens' Compulsory Entries        (4 - 7)   ____ x $70 = ______

accompany entry form.      Mens' Optional Entries          (8 - Elite) ____ x $80 = ______

                                    Womens' Compulsory Entries  (4 - 6)      ____ x $70 = ______

                                    Womens' Optional Entires       (7 - Elite) ____ x $80 = ______

                                    USAG Foreign Registration Fee               ____ x $25 = ______ 

                                    Teams   Womens'  4  5  6  7  8  9  10         

                                                    Mens' 4  5  6  7  8  9  10       ____ x $50 = ______

                                                           (Circle all that apply)

                                    Top 3 scores count for team score with one team per level.

         

                                             Total Entry Fee                                                 = _____

 

Make single club check payable to:      V.S.S.G.

Send Entry to:                                        Vitaly Scherbo Invitational

          3250 N. Bronco Street

          Las Vegas, NV 89108