KIDS FIRST SPORTS CENTER, CINCINNATI, OHIO

REGION V – CONGRESS

Test Administrators: = &nb= sp; = Betty Sroufe – Carole Arnaut

= &nb= sp; = &nb= sp; = &nb= sp;

The Exams will be given from: 8:00 AM to 12:00 PM

Final Times determined after All Early Registrations are received<= /p>

( Registered examinees will be notified of the definite time)

All level of written exams will be given. The practical exams will be decide= d upon early registrations. Level 10 practical will definitely be given. Level 9 & Level 8 practical will need a minimum of 5 participants each. SO, it is very importan= t that you get your registration in as early as possible.

FEES

Early Registration $25.00 per any part (by 7/3/04) IN HA= ND

= &nb= sp; = $35.00 per any part (AFTER 7/3/04)

= &nb= sp; = $40.00 per any part (ON SITE REGISTRATION)

PRE-RE= GISTRATION DUE DATE – JULY 15, 2004 (postmarked)

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REGISTRATION   FORM

Please r= eturn this form with your check for the FULL amount.

ALL FEES ARE<= /span> NON-REFUNDABLE!!=

Make check payable to:       Betty Sroufe/JCI

Send to: Betty Sroufe, JC= I/TA – 2096 Rolling Hills= Blvd Fairfield, OH 4= 5014

A copy of current rating card or exam results le= tter will be required (on site) to verify the exam you are eligible for. Also, make certain that your active status is current for the exam you are requestin= g to take. Any questions on this, = please call Betty Sroufe 513-829-5671

NAME:        =             &nb= sp;            =             &nb= sp;                = PHONE:        =             &nb= sp;         JN#      <= /span>

        =             &nb= sp;            =             &nb= sp;            =            CURRENT RATINGS:

ADDRESS:        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;

CIT= Y/STATE/ZIP:

Check those which apply:

Form A         is for the first time you test in 2004

Form B         is for the second time you test on previously failed exam in 2004

        =             &nb= sp; This is the first time I have tested

CIRCLE THE EXAMS WHICH APPLY:<= /b>

        =             &nb= sp;     PRACTICAL EXAM (Video)  &= nbsp; Level 8       Level 9         Level 10

        =             &nb= sp;     OPTIONAL LEVEL   &nb= sp;            =     7/8 Form A        = Form B

        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;             = 9 Form A        =    Form B

        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            10 Form A        =    Form B

        =             &nb= sp;      COMPULSORY LEVEL        =    5/6 Form A        = Form B