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Test Application - North Jersey FSC

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Test Application - North Jersey FSC

    North Jersey Figure Skating Club

    Test Application

    Please Complete BOTH Sides of This Form

    Completed application and test fees MUST BE RECEIVED THREE WEEKS BEFORE THE TEST DATE

    or the test will not be scheduled. Please mail this application to the Test Chairperson listed on the back.

    Candidate must be a member of the USFSA ONE MONTH BEFORE SCHEDULED TEST.

Candidate’s Name: ____________________________________________________________________________________ USFSA No: _____________________

    Address: _____________________________________________________ City ____________________________________ State ______ Zip _________________ Phone No. with area code: ( _______ ) _____________________________ Email _________________________________________________________________ Club through which your USFSA Number* is registered: ________________________________________________________ Age if under 18: _________________ *If your home club is not the NJFSC, a letter of permission from your test chairperson must accompany application.

    NJFSC Member? _____ Where do you wish to test? Ice Vault Floyd Hall Fritz Dietl Skylands TEST DATE: _____/_____/_________

    Moves and Free Skating Tests** Dance Tests

    Guest fee for non-NJFSC members ..................................................................... $35.00 Guest fee for non NJFSC members ....................... $35.00

    ADULT MOVES MOVES IN THE FIELD FREE SKATING TEST [ ] ADULT TEST [ ] MASTERS TEST [ ] SOLO

    TEST

     Circle dances to be taken Place checkmark in appropriate categories

    ___ Adult Pre-Bronze $35 ___ Pre-Prelim .............. $25 ___ Pre-Prelim .............. $25 Preliminary .............. $25 ea. DW CT RB

    ___ Adult Bronze......... 40 ___ Prelim....................... 30 ___ Prelim....................... 30 Pre-Bronze ................ 30 ea. SD CC FIT

    ___ Adult Silver ........... 50 ___ Pre-Juvenile ............. 35 ___ Pre-Juvenile ............. 35 Bronze ...................... 35 ea. HH WIW TF

    ___ Adult Gold ............ 70 ___ Juvenile .................... 40 ___ Juvenile .................... 40 Pre-Silver .................. 40 ea. 14S EW FT

    ___ Intermediate ............45* ___ Intermediate ............. 45 Silver ........................ 45 ea. AW T RF ADULT FREE

    SKATING TEST

     ___ Novice .....................70* ___ Novice ...................... 50 Pre-Gold ................... 60 ea. PD K BL SW

    ___ Pre-Bronze ............. $35 ___ Junior ......................75* ___ Junior ....................... 60 Gold .......................... 70 ea. VW WW QS AT

    ___ Bronze ..................... 40 ___ Senior .....................80* ___ Senior ...................... 70 Internationals ............ 95 ea. R MB AUS FS CON

    ___ Silver ........................ 50 SAM YP RW TR GW

    ___ Gold ......................... 60 Indicate the level this test completes:

    *NOTE: AS OF 9/2/10 INTERMEDIATE THROUGH SENIOR MIF, PLEASE INDICATE: ___ Pre ___ Pre-Bronze ___ Bronze ___ Pre-Silver [ ] STANDARD TEST [ ] ADULT TEST [ ] MASTER’S TEST ___ Silver ___ Pre-Gold ___ Gold ___ International

    ADULT PAIR TEST PAIR TEST

    (each candidate) (each candidate) FREE DANCE TEST

     ___ Bronze ............. $35 ___ Preliminary ............. $25 ___ Juvenile .................... $35

    ___ Silver .................. 50 ___ Juvenile .................... 35 ___ Intermediate ............... 45

    ___ Gold ................... 60 ___ Intermediate ............. 45 ___ Novice ........................ 50

     ___ Novice ...................... 50 ___ Junior ......................... 60

     ___ Junior ....................... 60 ___ Senior ........................ 70

     ___ Senior ...................... 70

    Revised September, 2010

    Hospitality Fee $ 5.00

    Test Fees $ __________

    Guest Fees $ __________

    Total Fees $ __________

Please make checks payable to North Jersey Figure Skating Club, Inc.

Please Note: A $40 fee will be charged for all checks returned by the bank for any reason.

    Applications may be withdrawn 20 days in advance of the test.

Test fees this season are not refundable.

Teaching Professional (please print): ______________________________________ Phone (_____) _____ -

    _________

    Signature of Teaching Professional:

    __________________________________________________________________

    Email of Teaching Professional: _____________________________________________________________________

Teaching Professional US Skating Number (MUST comply with US Skating Approved Coach Rules):

In submitting this form, I do hereby for myself (or as legal guardian), my heirs, executors and administrators waive, release

    and forever discharge any and all rights and claims for or to be, for which I may have or which may thereafter accrue to me

    against the United States Figure Skating Association, The North Jersey Figure Skating Club, Inc., its officers, board members,

    partner Ice Rinks and volunteers, and/or any person connected with individually or collectively, from all responsibilities for

    any injury and/or death to person or property. I understand that Skating is hazardous and assume the risk of injury or death.

__________________________________ ________________________

    Signature of Applicant Date

__________________________________ ________________________

    Signature of Parent or Guardian Date

    PLEASE NOTE THE FOLLOWING

    1. APPLICATIONS WILL NOT BE ACCEPTED VIA FAX, OR VIA E MAIL.

    2. APPLICATIONS WILL NOT BE PROCESSED WITHOUT AN ACCOMPANYING CHECK

    3. APPLICATIONS WILL NOT BE PROCESSED WITHOUT YOUR PRO’S SIGNATURE

    AND/OR PERMISSION SLIP FROM YOUR HOME CLUB.

    Mail this form with accompanying check to the appropriate chairperson.

    Ms. Kathie Imperatore 201-358-2643, FAX:201-690-9012

    613 Sloat Place

    River Vale, NJ 07675 Test Schedule is posted to www.northjerseyfsc.org

    Kathieim@optonline.net

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