Safety Registration 

Today's (laie'/'Q" . 77
Name '7
Social SeciirilyllA,  bi
Birth date 
USAG II 

Address A

  

 

 
 
 
  
 



Zip

Phone 

Course Code

   

 

   

Amounl (non member $100 inembm, [no or
members $50, curreni pro member is iree)

Qua card  I


Expii aliov


Card Holder's 

   
 
  

 

_'/Wumen's 
. iMen's (M)

 (R)
_General (GO)

 

'iwo Disciplines . i100"
Three Disciplines. $125
Four Discipiilies 
Trampoline &'i'unibiing('i) FiveDiscipiiries 175

__|nslrucim  "$40

a Minimum age fol'safely cer'iificfilion is i7 
a Monday, by 5:00 pm. is the last day regisil'alions be
accepied for courses Being conducted 2hr: following weekend

\w A 
firmer? \yx i;in
Pro Appiic (ion ngfi 49

USAG 0W3