Saturday Barker Middle School
319 Barker Road
February 5, 2011 Michigan City, Indiana 46360
$30.00 Registration Fee
PRE-REGISTRATION ONLY PLEASE!
Do NOT give this form or fees to your coach.
No spectator fee for those that come to show support for their child’s team. Remember your camera, camcorder and good sportsmanship!
No Food or Drink is permitted on the premises; concessions will be available throughout the day!
Order your engraved tape for your child’s trophy for only $5.00 (pre-order or order the day of the event).
DEADLINE TO PRE-REGISTER: Thursday, January 27, 2011
Registrations received after this date will be charged a $10.00 late fee.
THIS IS A NON-REFUNDABLE & NON-TRANSFERABLE REGISTRATION FEE
Mail Registration Form, Entry & Engraving Fees to:
Young Champions / INDIANA
165 54th St. SW, Wyoming, MI 49548
Make Check/M.O. payable to: Young Champions
Our trophy order is determined by pre-registered student totals. Please pre-register to alleviate trophy shortages.
DIVISION PRACTICE TIME PERFORMANCE TIME
1 8:00 A.M. 9:00 A.M.
2 11:00 A.M. 12:00 P.M.
3&4 2:00 P.M. 3:00 P.M.
*PLEASE PICK UP ENGRAVING TAPE AT THE ENGRAVING TABLE AT COMPETITION*
DETACH AND RETURN THE FORM BELOW TO YOUNG CHAMPIONS
Please check yes or no if you would like the engraved tape for your child’s trophy. $5.00 Yes __ No__
The name listed on this registration form is the name that will be placed on the engraved tape. Please write legibly.
Please check the division your child will be competing in:
Division 1 __ Division 2 __ Division 3 __ Division 4 __
Address City ___________________________State ______ Zip
Phone ( ) Coach
Pay by Check ___ M.O. ___ Please see reverse side if paying by credit card.
Registration $30.00 __ Engraving $5.00 __ Tee Shirt $12.00 __ Late Fee $10.00 __ Total Amount Enclosed $
THE WAIVER BELOW MUST BE SIGNED FOR YOUR CHILD TO BE ELIGIBLE TO PARTICIPATE.
Young Champions, Inc, Liability Release: I, the parent of the student listed above, do hereby agree to release all liability & claims against the Young Champions Inc. organization, & agree to hold harmless any
liability against Young Champions Inc., any sponsoring organization, facility, instructor and any other party involved, due to any injuries, accidents, negligence, or any other circumstance arising from
participation in this program with respect to any time prior, during and after the class, including participation in all Young Champions Inc. events such as parades, performances, clinics, competitions,
demonstrations, tournaments, etc. Parents and/or YC may take photos or videos of classes, parades or special events for personal/company use. I understand my child may be photographed. YC reserves
the right to refuse service to any customer for any reason.
Parent Signature: ____________________________________________________________________ Date: _______________
INDIANA CHEER COMPETITION
CREDIT CARD INFORMATION – Please fill out completely.
MasterCard __ Visa __ Registration $30.00 __ Engraving $5.00 __ Tee Shirt $12.00 __ Late Fee $10.00 __
Total Amount to Charge $
Name on card
Billing Address City State Zip
Credit Card # Exp. Date 3 Digit Security Code