LONG ISLAND SWIMMING

REGISTRATION

2003 – 2004

GROUP RATE PAYMENT DUE 10/20 2/1/04

DEVELOPMENTAL $800 $480 $320

JUNIOR $1,150 $690 $460

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JUNIOR ‘A’ $1,300 $780 $520

SENIOR $1,550 $930 $620

NATIONAL $1,800 $1,080 $720

CHECK IS PAYABLE TO LONGISLAND SWIMMING THIS CHECK MUST BE MARKED TUITION

YOUR CHILDS ENTRY FEE ACCOUNT WILL BE OPENED WITH AN ADDITIONAL CHECK PAYABLE TO LONG ISLAND SWIMMING FOR $115.00. THIS CHECK MUST BE MARKED ENTRY FEE

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NAME BIRTHDAY

FIRST MIDDLE INITIAL LAST

ADDRESS PHONE

TOWN ZIP

ATHLETE’S E-MAIL

PARENT’S NAME

PARENT’S E-MAIL

CELL PHONE(S)