Name Of Skater *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Name of Applicant if 18 or older signing / or Guardian signing *

First Name

Last Name

The USFSA and its member clubs conducting tests undertake no responsibility for damages or injuries suffered by test candidates. As a condition of and in consideration of the acceptance of this test application, the named test candidate/applicant (and their parents and/or guardians if a minor) agree to assume all risks of injury to the candidate/ applicant's person and property resulting from, caused by or connected with the conduct and management of the tests, and to release any and all claims which they have against any officials, the USFSA, the club hosting the tests and against their officers. *

I agree to the above / Signature

Skater's Professional *

First Name

Last Name

Professional's Phone *

(###)

###

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Test Track? *

Standard

Adult (21+)

Masters (50+)

Moves In The Field

check all that apply

Pre-Preliminary $15

Preliminary $20

Pre-Juvenile $30

Juvenile $35

Intermediate $45

Novice $50

Junior $55

Senior $60

Freestyle

Pre-Preliminary $15

Preliminary $20

Pre-Juvenile $25

Juvenile $30

Intermediate $35

Novice $40

Junior $50

Senior $55

Adult Moves In The Field

Pre-Bronze $25

Bronze $30

Silver $40

Gold $45

Adult Freestyle

Pre-Bronze $25

Bronze $30

Silver $35

Gold $45

Preliminary

Dutch Waltz $20

Canasta Tango $20

Rhythm Blues $20

Pre-Bronze

Swing Dance $20

Cha-Cha $20

Fiesta Tang $20

Bronze

Hickory Hoedown $20

Willow Waltz $20

Ten Fox $20

Pre-Silver

Fourteenstep $25

European Waltz $25

Foxtrot $25

Silver

American Waltz $30

Silver Tango $30

Rocker Foxtrot $30

Pre-Gold

Killian $35

Blues $35

Paso Doble $35

Starlight Waltz $35

Gold

Viennese Waltz $40

Westminster Waltz $40

Quickstep $40

Argentine Tango $40

International Dance

Austrian Waltz $40

Cha Cha Congelado $40

Golden Waltz $40

Midnight Blues $40

Ravensburger Waltz $40

Rhumba $40

Silver Samba $40

Tango Romantica $40

Yankee Polka $40

Solo or Partner Testing

Solo

Partner (Please Fill Out Data Below if Selected)

Partner's Name

First Name

Last Name

Partner's Phone

(###)

###

####

Free Dance Per Skater

Juvenile $30

Intermediate $30

Novice $35

Junior $45

Senior $55

Free Dance Solo

Juvenile $30

Intermediate $30

Novice $35

Junior $45

Senior $55

Adult Free Dance Per Skater

Adult 21 + and Adult 50 +

Pre- Bronze $25

Bronze $35

Silver $45

Gold $55

Pairs Per Skater

Pre Juvenile $25

Juvenile $30

Intermediate $35

Novice $45

Junior $60

Senior $65

Adult Pairs

Bronze $25

Silver $35

Gold $45