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Student Name: _______________________________________ Parent/Guardian Name: ________________________________ Address: ____________________________________________ City: _______________________________________________ State: ___________________ Zip: ___________________ Phone: _____________________________________________ Email: _____________________________________________ Date of Birth: _____/_____/_____ Age: ______ Gender: M or F Previous participation in LTS: Y or N Session:__________ Last badge received: ____________________________________ |
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USFS Basic Skills Membership $7.50 $______ (Good Sept 1, 2008-Aug 31, 2009) Winter I Sunday 5-6pm $87.00 $______ Monday 5-6pm $87.00 $______ Winter II Sunday 5-6pm $87.00 $______ Monday 5-6pm $87.00 $______ Winter III Sunday 5-6pm $87.00 $______ Monday 5-6pm $87.00 $______ Total $______ |
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Office Use Only: Payment Type Date Received:________________________ Cash: _______________________________ Check #: _____________________________ Credit Card #:_________________________ Expiration date: _______________________ |
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Snowplow Sam 1-3 Basic 1-4 Hockey 1-2 Adult 1-4 |