Entry Form

2nd Masters' International USA SINGLE DISTANCE CHAMPIONSHIPS, Milwaukee/USA, 07 - 08 Jan 2012
Please fill in this entry form completely and submit it. It will reach the organizer of the competition very fast.
Only use latin letters. Entry is expected until Sunday 19 Dec 2011 at the latest.
You will be informed by email about the arrival of your entry at the organizer. Additionally a list of entries can be found at:  http://mastersspeedskating.org .

Family name

First name

Complete Postal Address
(street, nr., postal code, town, province, country)

Email address





Date of birth

Starting for nation

National license no.


I will be attending the Reception:    yes/no

I will be attending the Banquet:    yes/no

Number of Guests at Reception:

Number of Guests at Banquet:

Mark the distances you want to race. Distances:

Saturday 500 m

Saturday 1.000 m

Saturday 3.000 m

Sunday 500 m

Sunday 1.500 m

Sunday 5.000 m

Your corresponding best time(s) must be quoted because of seeding. If no time is achieved this season, quote your best time previous season; if not available, quote etimated time:

Best time season 500 m

Best time season 1.000 m

Best time season 1.500 m

Best time season 3.000 m

Best time season 5.000 m


Entry Fee:
The entry fee 90 $ per skater has to be paid parallell to your entry to get registrated (except skaters from overseas). Please remit the entry fee to the bank account of the National Pettit Ice Center: TCF Bank, 500 W Brown Deer Rd, PO Box 170995, Milwaukee WI 53217-8096, Operating Account #3733920074, Bank Routing #275071385. Note as reference your name and "Masters Championships".
I hereby declare, that I am in good health and I am properly conditioned for the competitions. I absolutely relieve the organizer, the ISU, the IMSSC and the IMSSG of any responsibility for any injury, loss or damage to myself or my property or to accompanying persons or their property which may occur in the course of or in connection with the 2nd Masters' International USA SINGLE DISTANCE CHAMPIONSHIPS 2012 in Milwaukee/USA. Included in my declaration is the non-liability of the organizer according to ISU Rule 119, as expressed in the announcement of the competition.

I agree with the waiver

Several entries:   For sending several entries it may be necessary, not only to press the "Reset"-button and to fill in the form with the data of the following entry and to press again the "Submit"-button, but to reload the entry form for every new entry (depending on the browser used).

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