BATTLE OF CHAMPIONS - ENTRY FORM
	JANUARY 14-16, 2011
		Please mail Entry Form to:
	Pam Halker - Halker's Gold Gymnastics
		310 Birch
		Columbus Grove, OH  45830
Team Name:
Gym Address:			City:		State:	Zip:
Gym Phone #:		Gym Fax:			E-mail:
COACHES EMAIL:				TEAM NUMBER:
Coaches Name:		Coaches USAG #:			USAG Exp. Date:
Coaches Name:		Coaches USAG #:			USAG Exp. Date:
Coaches Name:		Coaches USAG #:			USAG Exp. Date:
_____ # of Level 3	$60.00   =	$	_____# of Level 7		$95.00  =	$
_____ # of Prep Optional	$75.00   =	$	_____# of Level 8		$95.00  =	$
_____ # of Level 4	$75.00   =	$	_____# of Level 9		$95.00  =	$
_____ # of Level 5	$75.00   =	$	_____# of Level 10/OPEN		$95.00  =	$
_____ # of Level 6	$75.00   =	$
___# of Teams ea. Lev.	$60.00   =	$	TOTAL AMOUNT ENCL.			$
Name	USAG #	Birthdate	Age	Level	T-Shirt Size	US Citizen