2012 Burlington Hockey & Skating Assoc. Basic Skills Winter Skate
Beyond Basic Skills Skate with U.S. Competition
Saturday, January 14, 2012
US Figure Skating Association Approved by US Figure Skating
Name___________________________________________________________ Sex ____ Birth date_____/______/_______
Last First
Address________________________________________________________ City ________________________________
State______ Zip______ _________Email Address___________________________________________________________
Area Code/Phone # (________)________-___________ US Figure Skating/ Basic Skills Number_____________________
Club or Program ____________________________________________________________________________________
Must be on application
Professional’s/Coach Name_______________________________________ Tel # ________________________________
Last Basic Skills/ Advance Skills Level Passed _____________________ex. Basic 3, Freeskate 5(As of December 15, 2011)
US Figure Skating Test Level:______________________________ (As of December 15, 2011)
REMINDER: All Snowplow Sam & Basic Levels 1 through 8 MUST SKATE AT HIGHEST LEVEL PASSED OR ONE LEVEL HIGHER.
Skaters in other Beyond the Basics events may skate at HIGHEST LEVEL PASSED OR ONE LEVEL HIGHER BUT NOT AT
BOTH LEVELS.
PLEASE CHECK THE EVENT(S) YOU ARE ENTERING:
Please check the event(s) you are entering:
Basic Elements: Free Skate Compulsory: Test Track & Well Balanced Compulsory:
______ Snowplow Sam ______Free skate 1 ______Limited Beginner
______ Basic 1 ______ Basic 5 _____Free skate 2 ______Beginner______ Basic 2 ______ Basic 6 ______Free skate 3 ______No Test______ Basic 3 ______ Basic 7 ______ Free skate 4 ______Pre-Preliminary_____ _Basic 4 ______ Basic 8 ______ Free skate 5 ______Preliminary ______ Free skate 6Basic Program: Free Skate Program: Test Track Program: Well Balanced:
______ Snowplow Sam ______Free Skate 1 ______Limited Beginner _______No Test ______ Basic 1 ______Basic 5 ______Free Skate 2 _______Beginner _______Pre-Preliminary ______ Basic 2 ______Basic 6 ______Free Skate 3 _______Pre-Preliminary _______Prelminary_____ _Basic 3 ______Basic 7 ______Free Skate 4 _______Preliminary_____ Basic 4 ______Basic 8 ______Free Skate 5
______Free Skate 6
Hockey Elements: Beginner Spins: Team Compulsories:
______Hockey 1 ______Basic Skills ______A $30 Per Team
______Hockey 2 ______Freeskate 1-6, Beginner, No Test ______B $30 Per Team
______Hockey 3 ______Pre-Preliminary ______C $30 Per Team______Hockey 4 ______PreliminaryENTRY FEE IS $40.00 PER EVENT, $25 SECOND EVENT, $15 EACH ADDITIONAL EVENT
First Event $ 40.00____
Second Event $ 25.00
Additional Event $ 15.00 **Make Check or Money Order Payable To: BHSA**
Total: $__________
The completed entry form, with fees, must be postmarked no later than December 15, 2011
Mail to: 2012 BHSA Beyond Basic Skills Winter Skate, Attn: Colleen Smith,
2 1/2 Pasho Road, Billerica, MA 01821Additional information: Colleen Smith@ CnCcleaning@verizon.net or you may call Colleen at 978-729-1350 .
Entry fees are not refundable after 12-15-11
Certification of Competitor: The Competitor is eligible to enter the events checked. It is agreed that the competitor and family holds
Burlington Hockey & Skating Assoc. harmless from any and all liability either during practice, or the competition, or from any and all liability
for damages to or loss of property.
**INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED-- ALL SIGNATURES NECESSARY**
Parent/Guardian Signature________________________________________ Email:______________________________
Professional/Coach Signature_______________________________________Email:______________________________
**Verify Levels Before Signing**
Program Director or Club Officer Signature______________________________________________________________
____________________________________________________________________________________________________
**Office Use Only: Date Rec’d______________________ Amount ____________________Payment Type_____________________________