NAME__________________________________________USFSA_________________________

ADDRESS_____________________________________________________________________

PHONE________________________________E-MAIL__________________________________

DATE OF BIRTH____________________                        MALE_________      FEMALE__________

NEICC CLUB AFFILIATION________________________________________________________
TIME OF MEMBERSHIP IN ABOVE CLUB____________________________________________
HIGH SCHOOL ATTENDING____________________________________________GPA_______
UNIVERSITY/COLLEGE________________________________________________2yr__4yr____
(LETTER OF ACCEPTANCE ATTACHED)

SKATING LEVEL_________________DATE PASSED_______________
HIGH SCHOOL/ COMMUNITY ACTIVITIES_________________________________

Essay attached (500 word max) ________

Club President signature___________________________________________________

Parent or guardian signature _______________________________________________
(under 18 yrs. of age)

By signing this, I testify as to the authenticity and originality of all represented in this  application.  I also attest that I did not receive assistance in preparing the essay, and that I understand my essay will become the property of the NEICC and may be published by them.

Applicant’s signature_________________________Date_______________

MAIL COMPLETED APPLICATION TO:
Rena Krane
23 Englewood Avenue
Everett, MA 02149-5404