________________________________________________________________
As they appear on your passport

ADDRESS: ______________________________________________________

CITY, STATE, ZIP: ________________________________________________

PHONE (h): _____________________ PHONE (w): _____________________

EMAIL: __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __
Please, one character per blank

PLEASE CIRCLE	Skiing Ability:	None	Some	Much
	Lesson Information Needed:	Yes	No
	Rental Equipment Needed:	Yes	No
	Interested in NASTAR:	Yes	No
	Room Preference:	Single	Double	Triple	Quad
	Do You Smoke:	Yes	No
	Roommate Preference:	_______________________

I am a member of the Champaign Ski Club, Inc. and I acknowledge the "Release of Liability" for trips, as outlined on my membership application.

Signature: __________________________________ Date: _______________

Fill out completely (print) and return with payment to trip planner.

Amount of deposit:

$ __________________

Make checks payable to:
Champaign Ski Club

In case of emergency,
contact:

____________________

Phone: _____________