2017 ICE BREAKER CHEERLEADING & DANCE CHAMPIONSHIPS REGISTRATION FORM

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1 Conexus Arts Center, Regina SK, Canada; Saturday February 4, ICE BREAKER CHEERLEADING & DANCE CHAMPIONSHIPS REGISTRATION FORM TEAM REGISTRATION RATES Regular registration deadline is January 9 th, Registrations received after this date and before January 27 th 2017 are subject to late fees (see below). Early Bird November 7 th, 2016 Cost is $20 per athlete per division if registration is received on or prior to this date. Regular November 8 th 2016 to January 9 th, 2017 Cost is $30 per athlete per division if registration is received between these dates. Late January 10 th to January 27 th, 2017 Cost is $40 per athlete per division if registration is received between these dates. No entries accepted after January 27 th, Please note: Registration forms and payment must be RECEIVED by the cut- off dates to qualify for rates indicated ADDITIONAL DIVISION RATES Group Stunt Division (Max. 5 people) - $25 per athlete Partner Stunt Division - $50 per pair Indy Tumbling Division (Tumbling, Jumps & Dance)- $30 per athlete Duo Tumbling Division (Tumbling only)- $50 per pair Demo - $15 per athlete INSTRUCTIONS 1. Fill out all items on registration form and determine total cost (include any applicable late fees). Please note that registration and payment must be RECEIVED by cut- off dates listed above. 2. Write a cheque payable to Ice Breaker Cheerleading Competition. 3. Mail your completed registration form and full payment (see mailing address below). 4. Send us an to let us know that you are planning to attend Icebreakercheer@sasktel.net 5. Your registration and payment must be received by January 27 th 2017 no entries accepted after this date. Your entry is not complete until your registration form is completed in full and both the form and payment have been received. If you have any questions, please feel free to contact us at Icebreakercheer@sasktel.net or check out our website at Looking forward to seeing your team! Ice Breaker Staff

2 School/Club Name: School/Club Mascot: Coach name(s) Primary Contact Name(s) Full Address: Postal Code: Primary Contact Cell Phone: Date: DANCE DIVISIONS (for available divisions, please consult sca.ca/rules- scoring) TEAM NAME CATEGORY AS, ELM, HS DIVISION (Pom/ Jazz/ Hip Hop) LARGE OR SMALL ALL- GIRL OR CO- ED # Of Males TOTAL # OF ATHLETES COST PER ATHLETE TOTAL PER TEAM Total $ CHEER DIVISIONS (for available divisions, please consult sca.ca/rules- scoring) TEAM NAME CATEGORY AS, ELM, HS DIVISION (Mini, Senior etc.) LEVEL LARGE OR SMALL ALL- GIRL OR CO- ED # Of Males TOTAL # OF ATHLETES COST PER ATHLETE TOTAL PER TEAM Total $

3 ADDITIONAL DIVISIONS - Group Stunt, Partner Stunt, Indy Tumbling, Duo Tumbling, Demo (Levels 1-6) (please specify below) * Please complete additional information on following pages Group Stunt, Partner Stunt, Indy Tumbling, Duo Tumbling, and Demo Level AGE(S) TOTAL # Of Athletes Cost per Athlete Total per division Total $ PAYMENT INFORMATION GRAND TOTAL FOR FEES $ AMOUNT ENCLOSED $ PAYMENT TYPE ENCLOSED (please circle): CASH CHEQUE Registration Form & Payment is required no later than by Friday, January 27 th, 2017 Please make cheques payable to Ice Breaker Cheerleading Mail to: Ice Breaker Cheerleading N Castle Road Regina, SK, S4S 4W1 Or forms or other inquiries to: Icebreakercheer@sasktel.net For more event information, please visit our website at Or e- mail Icebreakercheer@sasktel.net for further inquiries Follow us on Like us on Facebook: Ice Breaker Cheerleading & Dance Championships Follow us on

4 GROUP STUNT ATHLETES (Levels 1-6) Group 1 - Names Group 2 - Names Group 3 - Names Level: Level: Level: Age(s): Age(s): Age(s): PARTNER STUNT ATHLETES Partner 1 - Names Partner 2 - Names Partner 3 - Names Level: Level: Level: Age(s): Age(s): Age(s): INDY TUMBLING ATHLETES (Tumbling, Jumps & Dance) (Levels 1-5) Name Level Name Level DUO TUMBLING ATHLETES (Tumbling only) (Levels 1-5) Duo - Names & Level Duo Names & Level Duo Names & Level Duo - Names & Level Duo Names & Level Duo Names & Level

5 CROSSOVER ATHLETES CROSSOVER ATHLETE Is ANY athlete(s) competing on more than one team, or in more than one routine at Ice Breaker. This includes those teams within your own school/club and all other schools/clubs. Please include ALL athletes (any in Dance, Cheer, Group Stunt, Partner Stunt, Indy & Duo Tumbling routines competing at Ice Breaker) from both your own school/club and others. Please ask your athletes which other routines they will be competing in prior to sending in your registration. Team/Routine (including group, partner and tumbling) Crossover Team, Or Routine (including group, partner and tumbling) TEAM ROSTER ATTACHED? YES (mandatory) NOTES: This is a SCA Sanctioned Competition. Refer to SCA Rule Book for divisions, division splitting/combining and rules - Saskatchewan teams must hold a paid SCA Membership to be eligible to compete. A tentative schedule will be made available after the close of registration. It is your responsibility to immediately review the schedule and notify the Event Host of conflicts in order that they can be resolved before the schedule is finalized. Changes are not possible after the schedule has been finalized. Out- of- province teams: It is your responsibility to ensure that your insurance covers practice & competition out of your home province. * If you are travelling from out of the Province of Saskatchewan, please have each of your athletes complete our athlete waiver and submit upon arrival at the Registration Check- In Desk. Please do not send by mail. Athlete waiver can be found at: (under Registration tab). EVENT INFORMATION For more event information, please visit our website at Or e- mail Icebreakercheer@sasktel.net for further inquiries Follow us on Like us on Facebook: Ice Breaker Cheerleading & Dance Championships Follow us on

6 OFFICIAL TEAM ROSTER Please list all team members below by name with their competing age (age that they will be when competing at Ice Breaker for the season). Coaches must fill out an official team roster for each team entered in the competition and submit it with the team registration and fees by the deadline. Please note that a maximum of two coaches passes per team will be provided (for COACHES only) for the event. All teams must be willing to provide personal identification for each member verifying age and registration. Please print all information clearly and keep a copy for your records. Be sure to report any changes to the Ice Breaker Event Host at Icebreakercheer@sasktel.net prior to the competition. School/Club Name: Coach name(s) *FOR ROSTER, PLEASE PROVIDE US WITH TEAM COACH (NOT ADVISOR) NAME AND CONTACT* By submitting this form I verify that our team holds a current Saskatchewan Cheerleading Association membership, OR, if from out of Province, I verify that each member of the team has personal accident insurance. I also give permission to use the team s likeness for social media and broadcasting purposes for the event. Coach s Signature: Date: ATHLETE NAME AGE ATHLETE NAME AGE *Please provide the names of Coach(es) who will be receiving a coaches backstage access pass (Maximum 2 per team) COACHES ONLY. COACH NAME COACH NAME COACH NAME COACH NAME COACH NAME COACH NAME