BURGGRAF ISOTM 2009 AUGUST 3RD - 14TH

INDIVIDUAL ISOLATION CLINICTM ENROLLMENT FORM

** Deposit of $300 Required w/Enrollment Form Received by February 1st.

Groups - Select one Select One... Group 1 - 2nd year Squirt / Pee Wee - $650 Group 2 - Bantam - $850 Group 3 - High School - $1,180 Group 4 - Limited Advanced - $1,300

Please clickInformation Registration form for more information of each group

to determine which you should choose. If you still have question please use the

Contact Us option in the menu bar.

* Indicates a required field

Email Address A value is required.

Phone *

Address *

Address

City *

State *

Zip *

Medical Insurance Company *

Policy Number *Previous Injuries *

Level of Play Next Year *Position *

Weight *Height *Age *Shoots Select... Left Right

Allergic Reactions or Allergies *

Emergency Contact *

Emergency Contact Phone # *

Parent / Guardian Name(s) *

Are you interested in housing an out of town sakter or do you need housing select... Yes No I need housing

T-Shirt Size select... Small Medium Large XL

Group 4 Only - Waist Inseam

Payment method select... Check Credit Card To help with security: for credit card payments, we will contact you once we received your registration.

Make checks payable to: Burggraf

Mail to: Burggraf Skating, 6332 13th Street N, Fargo, ND 58102

Phone: 701-293-5553

Fax: 701-293-9406

Verify information, when complete use the Submit to register. Before your registration is complete you will need to pay the registration fee based on the group you registered for.

Once you Submit you will be brought back to the HOME page