2006 BOWL QUALIFIER

CONTEST LOCATION:  ________________________________.

CONTEST DATE : ____________________________________________

ENTRY FEE :   $25.00(CASL MEMBERS)   $45.00(NON-MEMBERS)

AMOUNT PAID $___________________________________________(cash or check #________________)

NAME:_______________________________________________________________________AGE:___________

                                                FIRST                                    MIDDLE                                LAST

ADDRESS:____________________________________________________________________________________

                            STREET NUMBER & NAME             APARTMENT #                CITY                                      STATE                        ZIPCODE

HOME PHONE: (_______)________________________SHIRT SIZE:___________SHOE SIZE:___________

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FAVORITE PLACES TO SKATE:___________________________________________________________________________

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OTHER FAVORITE THINGS TO DO:____________________________________________________________

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EMERGENCY INFORMATION

SPECIAL MEDICATION; ALLERGIES;MEDICAL RESTRICTIONS________________________________________________

IN CASE OF EMERGENCY PLEASE NOTIFY:

(1)_____________________________________________PHONE:____________________RELATIONSHIP:__________________

(2)_____________________________________________PHONE:____________________RELATIONSHIP:__________________

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INSURANCE CARRIER:_______________________________________MEDICAL CARD #:__________________________

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FOR OFFICE USE ONLY:  FEES _______________   PAID: (cash)  (check # __________________)

EVENT ENTERED:      (UNSPONSORED AMATEUR)      (SPONSORED AMATEUR)    (OPEN/MASTERS)