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2021-22 Figure Skating CoE Questionnaire
Skater Contact (As it appears on passport or ID)
Student Name
Preferred Name or Nick Name
Student's Age
11
12
13
14
15
16
17
18
19
Grade Entering
6
7
8
9
10
11
12
PG
Student's Birthdate
Currently Enrolled at SSM
*
Yes
In Process
Inquiring for future date
Registered Tier Level
*
Tier I Gold
Tier II Silver
Tier III (12th & PG Only) Bronze
Street & Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo (Democratic Rep)
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland (Republic)
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Zip Code
Student Cell Phone Number
Local News Paper
I Plan to Attend Pre-Season Training
*
Yes
No
Date Arriving to School
Leggings / Joggers Size
*
Child Small
Child Med
Child Large
Adult X-Small
Adult Small
Adult Med
Adult Large
Adult X-Large
Leotard
*
Child Small
Child Med
Child Large
Adult X-Small
Adult Small
Adult Med
Adult Large
Adult X-Large
Skating Skirt
*
Child Small
Child Med
Child Large
Adult X-Small
Adult Small
Adult Med
Adult Large
Adult X-Large
Warm-Up Jacket Size
*
Child Small
Child Med
Child Large
Adult X-Small
Adult Small
Adult Med
Adult Large
Adult X-Large
Outerwear Vest
*
Child Small
Child Med
Child Large
Adult X-Small
Adult Small
Adult Med
Adult Large
Adult X-Large
Comments
Parent Contact
Mother First Name
Mother Last Name
Father Last Name
Father Last Name
Country Phone Code
Home Phone Number
Mother Cell Phone Number
Fathers Cell Phone Number
Mother Email Address
Father Email Address
Comments
Skater Profile
Highest (USFS) FS Test Passed
Preliminary
Pre-Juvenile
Juvenile
Intermediate
Novice
Junior
Senior
Non of the above
Highest MIF Test Passed
Preliminary
Pre-Juvenile
Juvenile
Intermediate
Novice
Junior
Senior
Non of the above
Highest Dance Test Passed
Preliminary
Pre-Bronze
Bronze
Pre-Silver
Silver
Pre-Gold
Gold
Non of the above
Other Tests
USFS # (If you know)
Competitive Discipline Involvement
1. Competitive Singles
2. Recreational Singles
3. Ice Dance
4. Synchronized Skating
Event Description
IJS (Highly Competitive)
Well Balanced (Moderately Competitive)
Not Sure
Classify Competitive Involvement
1. Recreational
2. ISI
3. USFS Test Track
4. IJS Competitive
5. International
International Students: Do you plan on competing at your National Championships this season?
Yes, I meet rthe requirments
No I am not prepared at this time
Synchro only skater (does not apply)
Current International Level Competing
International Federation & Club
Current Summer Training Schedule
Skater is prepared (today) and intends to compete Sept. 9th
1. Yes, my programs are complete and I have trained this summer for competition
2. No I am not prepared at this time
Ice Hours Per Day
1
2
3
4
5
Lesson Hours Per Week
1
2
3
4
5
6
7
More
How Many Programs Per Week
0
1
2
3
4
5+
Dance Class Per Week
1
2
3
More
Non of the above
Conditioning Per Week
1
2
3
More
Non of the above
New Program / Routine
1. Programs / routines are choreographed
2. I need new programs / routine
Music
1. I have edited music
2. I need new music
Dress / Costume
1. I have dresses / costumes
2. I need new dresses / costumes
Skates
1. I have skates that fit and not broken down
2. I need new skates
Comments
Goals & Objectives For Skater & Parent
Skaters competitive expectation
*
Highly Competitive / Expect to Win
Moderately Competitive / Personal Best
Recreational / Pure Enjoyment
None of the above
Parent expectations of your skater
*
Highly Competitive / Expect to Win
Moderately Competitive / Personal Best
Recreational / Pure Enjoyment
None of the above
Ballet Training (parent & student must agree)
*
I plan on attending ballet class 100% as training
I do not plan on attending ballet class
Strenght Training (parent & student must agree)
*
I plan on attending strength class 100% as training
I do not plan on attending strength class
I (skater) understand I will be held accountable for attending required training sessions/classes
*
Yes
No
What are your long term goals as a skater?
*
What are your goals for this year?
*
What are your strengths and weaknesses?
*
What suggestions do you have to help improve these weakness?
*
Items or concerns we should know?
*
I have read and understood the Figure skating "Athlete & Parent Information" document.
*
🛈
Yes
Coaches Contact
Head Coach First Name
Head Coach Last Name
Phone Number
Email Address
Do you wish to continue with coach
Yes
No
Comments
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