Koach Allstars 2014-2015 Allstar Tryouts April 6th and 13th 2014 Alternate date April 9th 2014 Koach Allstars would like to welcome you to the 2014-2015 allstar season! We are excited to start our second year of allstar cheerleading! To all of our returning athletes Thank You for making our first season a great success! We are excited to get you back in the gym to prepare for another great year. To all of the athletes new to the gym we are excited that you are considering joining the Koach family and would like to tell you a bit about our program. Ko-ach comes from the Hebrew term meaning "Strength" and we will use this program to teach "strength" in all aspects of life. Our gym’s mission is to teach athletes the sport of competitive cheerleading and tumbling. However we believe that this program will do more than just improve cheerleading skills. We will use cheerleading as a tool to help individuals gain strength by teaching discipline, leadership, camaraderie, good sportsmanship and teamwork. Practices/Time Commitment: At Koach we pride ourselves on our family oriented environment. Practices will be during the week in order to allow for family time during the weekend. Practices are very important toward the overall success of the team. Our practices are required. Tiny will practice once a week for 1 ½ hours. Mini will practice twice a week for 1 ½ hours each practice. Youth through Senior will practice twice a week for two hours each practice. All athletes on a level 3 team or higher will be required to take one tumbling class per week. The cost of this class is included in your monthly tuition. As competition season nears, we may call extra practices beyond a team’s normal schedule. Choreography Camp: Choreography camp is required for all teams mini and up. Camp will be June 2nd – June 8th. Specific team schedule is TBD. Competitions: Competitions will fall on weekends from October through April. We have included a tentative competition schedule in this tryout packet. Please note that dates may change. Competitions will be both local and out of state. All competitions are required. No exceptions. Travel fees are not included in monthly tuition and competition fees. Fees: Cost Competitive cheerleading is not the most expensive activity on the market, however it does require a financial commitment. Entry fees for competitions alone can be hundreds of dollars over the course of a cheer season. Before making your decision if this is a sport for you and your family carefully consider the financial commitment. Please see the price sheet listed below for estimated costs and take note that these costs due not include travel expenses. All fees are non-transferable and non-refundable. All accounts must be in good standing before athlete is able to tryout. Team Guidelines Teams are formed based on ability and age. Please see below for tumbling guidelines. Some exceptions may be made. An athlete’s maturity and ability level as well as team needs will be taken into consideration when forming teams. With this being said we truly believe that an athlete will excel when placed on an age and ability appropriate team. Level 1: Cartwheel/Roundoff, Backbend/Bridge kick over, Front and Back Walkover, Cartwheel Back Walkovers Level 2: Level 1 skills plus standing Back Handspring, Roundoff Back Handspring, Round Off multiple Back Handsprings, Back Walkover Back Handspring, Front Walkover Roundoff Back Handspring, Toe Touch pause Back Handspring Level 3: Level 1&2 skills plus Standing multiple back handsprings, Roundoff Back Handspring Tuck, Toe Touch Back Handspring, Multiple Jumps to Multiple Back Handspring, Front Walkover Roundoff Back Handspring Tuck, Punch Fronts, Back Handspring Step Out through to Tuck Level 4: Level 1-3 skills plus Standing tuck, standing Back Handspring Tuck, Roundoff Back Handspring Layout, and Standing Back Handspring(s) to Layout, Front punch through to layout. Level 5: Level 1-4 skills plus multiple jumps to tuck, Roundoff Back Handspring Full, Standing Back Handspring(s) to Full/Double Full Teams are also determined by age. Some exceptions to age may be made. An athlete’s maturity and ability level as well as team needs will be taken into consideration when forming teams. With this being said we truly believe that an athlete will excel when placed on an age and ability appropriate team. Tiny: Ages 3-5 as of 8/31/2014 Mini: Ages 6-8 as of 8/31/2014 Youth: Ages 9-11 as of 8/31/2014 Junior: Ages 12-14 as of 8/31/2014 Senior: Ages 15-18 as of 8/31/2014 *No athlete under the age of 10 will be allowed on a senior level team due to USASF rules and regulations. Open: Ages 17 and Up Koach Allstars 2014/2015 Price List Paid once per season: May1st, 2014 - April 30th 2015 Registration: Cost $150 Due Date May 1st This fees covers office fees, insurance, USASF membership and equipment fees. Competitive Cheer Monthly Tuition: Cost Due Date Tuition fees include weekly practices, 1 tumbling class per week and unlimited open gyms. Tuition is due on the 1st of the month. After the 10th of the month a late fee will be added. Tiny $55/month Mini $65/month Youth $75/month Junior $75/month Senior $75/month 1st 1st 1st 1st 1st Additional Fees for Allstar Cheer Teams Cost Due Date Practice Clothes 1 tank top, 2 t-shirts, 2 shorts 2 bows Choreography – This price may vary depending on size of teams Uniform (Year 2 of 2) Warm Ups (Year 2 of 2) Bow Shoes (New every year) Competition Shirt – designed and decided on as a team $80 $250 $250 $75 $25 $95 $20 May 1st May 1st June 1st June 1st June 1st July 1st Sept. 1st Competitions of of of of of month month month month month Cost Due Date All dates and costs are subject to change. Dates with * have not been confirmed for the 2014-2015 season. When those dates are released we will let you know asap. Please take note that these prices do not include travel expenses. $72/participant Sept 1st October 11, 2014 Jamfest Mega Jam Series Jamfest Peoria, IL $25 Coaches Fee Sept 1st October 26, 2014 Pre-State Premier Ankeny High School Ankeny, IA $10/participant November 9, 2014 November 15, 2014 Cheering For a Cause Iowa Showdown Apex Champion Spirit Group Des Moines, IA Des Moines, IA December 6, 2014 Hawkeye Challenge UCA Des Moines, IA January 11, 2015 Xtreme Spirit Xtreme Spirit Des Moines, IA January 25, 2015 *February 8, 2015 Whirlwind Challenge Battle for the Behemoth GLCC Iowa Elite Independence, MO Cedar Rapids, IA February 14, 2015 Rolling Prairie GLCC Des Moines, IA February 14-15, 2015 The American Heartland Kansas City Grand Championship MidAmerican National Championship The Amer. Champ. Council Bluffs, IA March 7, 2015 March 28-29, 2015 Cheersport COA Kansas City, MO Kansas City, MO $25/participant $5 Coaches Fee $35/participant $5 Coaches fee $40/participant $5 Coaches fee $60/participant $5 Coaches Fee $72/participant $25 Coaches Fee $35/participant $10 Coaches Fee $72/participant $5 Coaches Fee $95/participant $25 Coaches Fee $65/participant $15 Coaches Fee $99/participant $25 Coaches Fees Oct. 1st Oct. 1st Nov. 1st Nov. 1st Dec 1st Jan. 1st Jan. 1st Feb. 1st Feb. 1st March 1st April 3, 2015 Koach Allstars Premier Koach Ankeny, IA $0 Competition Payment Options Pay on Due Date or Pay $138.34 per month Sept-Feb Any team that receives a Bid during the season WILL be going to the Bid Awarded Competition. 2014-2015 Koach Allstars Tryouts To be completed and turned in at tryouts Please Print Clearly Athlete Information: Athlete Name: ____________________________________________ Age as of 8/31/14:_____________ Street Address: ______________________________________________________________________________ City: _________________________________ State: _______________________ Zip: __________________ Home Phone: ____________________________ Cell Phone: _______________________________ Athlete email address: _______________________________________________________________________ Any known allergies: _______________________________________________________________________ Parent Information: Email is our main way of communication. Please leave an email address for an account that you check regularly. Mother’s Name: _______________________________________ Work Phone: ____________________________ Cell Phone: ______________________ Email: _________________________________________ Father’s Name: _______________________________________ Cell Phone: _______________________ Work Phone: ____________________________ Email: _________________________________________ Address if different from athlete: _______________________________________________________________________________________________ Emergency Information: Contact other than parents Name: _________________________________________ Phone Number: ____________________________ 2014-2015 Koach Allstars Tryouts Athlete Survey To be completed and turned in at tryouts Please Print Clearly Athlete’s Name: ________________________________________________ Age as of August 31st 2014: ________________ Skills: Have you been a part of an allstar cheerleading team? Yes No If yes where and at what level: ________________________________________________________________________________ What is your highest level of tumbling? ______________________________________________________________________ Do you have any skills that you are close to achieving? ______________________________________________________ Do you have a specialty pass? Yes No If yes please list: ______________________________________________________________________________________________ Circle all that you have experience with in stunting. SIDE BASE BACK BASE Preferred Team Level: Tiny Preferred Tumbling Level: FLYING Mini 1 2 Youth 3 ONE-MAN Junior 4 Senior 5 No Preference No Preference Practice Gear: 1 tank top, 2 t-shirts, 2 shorts and 2 bow Tank Top Size: YS YM YL AS AM AL AXL T-Shirt Size: YS YM YL AS AM AL AXL Shorts Size: YS YM YL AS AM AL AXL Coaches Use Only: Jumps: 1 2 3 Comment: _______________________________________________________________ Standing Tumbling Level ________________ Comment _____________________________________________________ Running Tumbling Level ________________ Comment ______________________________________________________ Level of Current Stunting ________________ Comment______________________________________________________ Medical History and Release Form 2014-2015 To be completed and turned in at tryouts. Athlete Name: ________________________________________ DOB: _______________ Address: ____________________________________ City: _________________ State: ______ Zip: ______________ Do you have any allergies? __________________________________________________________________________ Do you wear: Glasses Contacts Dental Retainer Insulin Pump Other: ______________________________________________________ Primary Care Physician: _________________________________________________________________ Address: _____________________________________________ Phone Number: _________________ Primary Dentist: _________________________________________________________________________ Address: _____________________________________________ Phone Number: _________________ Primary Insurer’s Name: ___________________________________________________________ Address: __________________________________________________________________________ Home Phone: _________________ Work Phone: _____________________ Cell Phone: ____________________ Medical Insurance Company: ________________________________________________ Medical Insurance ID Number: _______________________________________________ Medical Insurance Group Number : __________________________________________ Secondary Insurer’s Name: ________________________________________________________ Address: __________________________________________________________________________ Home Phone: _________________ Work Phone: _____________________ Cell Phone: ____________________ Medical Insurance Company: ________________________________________________ Medical Insurance ID Number: _______________________________________________ Medical Insurance Group Number : __________________________________________ TO ANY DOCTOR OR HOSPITAL CONSENT FOR MEDICAL TREATMENT: The undersigned, parent of the above named minor child who is participating in cheerleading and/or tumbling at Koach Allstars or with Koach Allstars, recognize that my child may sustain an accidental injury at a time when I am not present and cannot be contacted. Therefore I nominate Ashley Bailey and/or Koach Allstars Staff full power and authority, in a situation of urgency, to execute on my behalf such documents of admission to a hospital as are necessary and to consent to such tests as the doctor feels are in my child’s best interest under the circumstances. I am granting Ashley Bailey and Koach Allstars Staff authority to do and perform each act required and necessary to be done fully as if I were present. This power shall be effective from May 1, 2014 until April 30, 2015. Parent’s Signature: _______________________________________________ Date: __________________ KOACH ALLSTARS - Participant Agreement, Release and Assumption of Risk Athlete’s Name: ___________________________________________ Birthday: ________ /_______ /_______ Athlete’s Cell: _________________________________ Athlete’s Email:______________________@____________________ Mother’s Name: ___________________________ Mother’s Cell: ____________________ Email: ____________________________ Father’s Name: __________________________ Father’s Cell: _____________________ Email: _____________________________ Home Address: ________________________________________________ City_______________________ Zip________________ In consideration of the services of Koach Allstars, its owners, agents, officers, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter referred to as Koach Allstars), I hereby agree to release, discharge, and hold harmless Koach Allstars on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate as follows: 1. I understand and acknowledge that the activities that I or my child engage in while under the instruction of Koach Allstars pose known and unknown risks which could result in injury, paralysis, death, emotional distress, or damage to me, my child, to property, or to third parties. 2. I agree and promise to accept and assume all the risks, known and unknown, connected with CCC-related activities, including but not limited to performance of stunts and use of trampolines and inflatables. My participation and that of my child is purely voluntary. 3. I hereby voluntarily release, forever discharge, and agree to hold harmless and indemnify Koach Allstars from any and all liabilities, claims, demands, actions, or rights of action, which are related to, arise out of, or are in any way connected with my child’s participation in Koach Allstars -related activities. 4. Should Koach Allstars incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and reimburse them for such fees and costs. 5. I certify that my child has health, accident, and liability insurance to cover bodily injury or property damage that may be caused or suffered while participating in this event or activity, or else I agree to bear the costs of such injury or damage to my child. 6. I agree to allow Koach Allstars the right to use any pictures, video or other media taken of my children, myself or other family members for the production of advertisement materials, website, flyers, mailers, postcards, or other forms of advertisement. 7. I agree that I am financially responsible for all charges occurred while at Koach Allstars. 8. I have read this entire document and understand it. I agree to abound by its terms. Signature of Parent/Guardian: ______________________________________ Print Name: ____________________________________________________ Date: ___________________ Koach Allstars Credit Card Agreement To be completed and turned in at tryouts. Your athlete can not practice until this form is returned. Requirements This year our gym in going to implement a required credit card on file for every all star member. This will help to keep everyones costs down by ensuring that payments are made. This credit card can be the same as your auto withdraw card however if your account is 30 days overdue this card will automatically be charged on the 10th of the month and will have a $25 fee added to account if declined. Debit cards will not be accepted. Credit Card Information I understand that my credit card information is mandatory for my child to be able to participate in the Koach Allstars cheerleading program. I understand that if my account is more than 30 days overdue that my card will be charged on the 10th of the following month and that I will incure a $25 charge if my payment is declined. I understand that I can not have my debit card as my required credit card. Card Type: Visa Mastercard Discover Name on Card: _________________________________________________________________ Mailing address for card: _________________________________________________________ City, State, Zip: ______________________________________________________________ Credit Card Number: ________________________________________________________ CV Code: _________________ Exp. Date: ________________________ Signature: _________________________________________________ Monthly Auto Withdrawal Form Optional Monthly auto withdrawal form will be available for automatic withdrawal for the following but not limited to monthly tuition, tumbling, private lessons, competition fees, cheerleading equipment and apparel. All amounts will be taken out on the 10th of every month according to the program cost schedule available at the office or on our webpage at www.koachallstars.com. Please indicate which items you would like to be taken out automatically. These amounts are nonrefundable. If you decide to leave the program we will need a 30 day written notice to stop ALL charges. Monthly Tuition: YES NO $__________________ Monthly Tumbling: YES NO $__________________ Private Lessons: YES NO Amounts will vary Competition Fees: YES NO Amounts will vary All Monthly Fees: YES NO Amounts will very I __________________________________ agree to give Koach Allstars my debit/credit account information and understand that it will be an auto withdrawal form of payment on the 10th of each month. If payment is declined there will be a $25 service fee per transaction. You will need give a written 30 day notice of withdrawal for all monthly fees to stop. Check here if you would like this to be the same as your required credit card Name on the card: ___________________________________________________________ Billing address: ______________________________________________________________ Card Number: _______________________________________________________________ Exp. Date: __________________________ Code on back: ____________________ Email: ________________________________________ Phone: _____________________ Check here is this is a debit card. Athlete’s Name: _____________________________________________ Koach Allstars 2014-2015 Program Handbook Please keep this handbook for future reference. Coaching Philosophy: Our gym’s mission is to teach athletes the sport of competitive cheerleading and tumbling while striving to teach tools for life. God and prayer will be openly welcomed in the gym. We believe that Christ is the center and we welcome anyone to partake. While we strive to make each athlete reach their highest cheerleading potential, we believe that this program will do much more than just improve cheerleading skills. Throughout one’s life we will be all faced to work with others for different situations, we take pride in working with a team in order to reach common goals. Whether it’s on the mat, professional, school, or social setting the athletes will strive to better themselves and their peers. Teamwork is much more valuable than the actual physical skills they achieve.We hope prayer can bring together their team and their hearts to be great community members. Dream Big and Go After IT! With God ALL things are possible. Mathew 19:26 What is All Stars? “The sport of All-Star Cheerleading has grown immensely from its roots over 20 years ago. In the 80s and early 90s, teams were typically formed of athletes who were interested in improving their skills so that they would stand a better chance of making their high school or college cheerleading teams. As the sport developed and grew, more and more athletes and their parents viewed All-Star Cheerleading as a viable activity in and of itself. As stronger and stronger athletes began to recognize that All-Star provided them a way to focus more on teamwork and athleticism and less on pom pons and decorating lockers, the sport began to separate itself from the traditional stereotypes. This is no longer your mother’s Cheerleading. Teams and athletes in All-Star now focus on gymnastic and acrobatic moves. The hybrid sport of today is a combination of gymnastics, acrobatics, athletic dance, and many elements unique to All-Star. More extreme athlete than fashion model, today’s All-Star athlete can learn exciting skills in a fun, safe environment. All-Star teams are typically comprised of 15-36 athletes with a variety of skills and abilities (much like a football or basketball team.) There can be solid, well-rounded athletes and those who have particularly strong abilities in certain areas (ex. - strong dancers or jumpers). The coaches create a competition routine performed by the group that has elements of tumbling, stunting, jumping, dance, and other skills set to music. The routines are typically 2 1/2 minutes in length. At competitions, the teams are divided by age and ability level. The routines are judged by their level of difficulty, precision, creativity, and entertainment value.” Cheer Athletics will choreograph our routines. “All-Star Cheerleading is a great way for young athletes To learn new skills while building teamwork, goal-setting, sportsmanship, and the social skills to make lifelong friendships.” Expectations: Time Commitment Practices are very important toward the overall success of the team. ALL practices are required. School related absences need to be submitted to the gym at least 1 week in advance in order for our coaches to plan accordingly for practices. Practices will be during the week in order to allow for family time during the weekend. As competition season nears, we may call extra practices beyond a team’s normal schedule. Anyone who misses the practice before a performance will not be permitted to perform. If attendance becomes a concerning issue you may be dismissed from the team for the remainder of the season. Program Cost Competitive cheerleading isn’t the most expensive activity on the market, however it does require a financial commitment. Entry fees for competitions alone can be hundreds of dollars over the course of the season. Before making your decision if this is the sport for you and your family carefully consider the financial commitment. Please see the price sheet listed for estimated cost and keep in mind that this does not include travel expenses. All tuition and expenses are non-transferable and non-refundable. Tryouts Current staff and coaches will be the judges of tryouts. All athletes will be placed on a team determined by their age, level of tumbling, and level of stunting. Team results will be posted on the Koach website www.koachallstars.com by 8 p.m. April 20th, 2014. Teams Once on a team, Koach Allstars will have the right to move an athlete from one team to a different team as we see fit. Spots within a team are not guaranteed and at any time an athlete may be moved or changed in the routine to make the best possible product on the mat for competitions. We hope you will respect coaches and their choices. Any concerns with practice or coaching technique need to be addressed in private and outside of practice time. Tumbling Requirement One tumbling class per week is required for all athletes on a level 3 team and higher. This tumbling class is included in your monthly tuition. If your regular class is missed you must make it up in a preapproved class. Choreography Choreography dates are required. Our routines will be done by Cheer Athletics near Dallas, Texas. His prices vary depending on the number of teams as well as hotel expenses while they are in town. This cost is required for all members even if joining later in the season as they still have to take the time out of practice to learn the choreography. We are so blessed to have such a great mentor gym. God Bless Texas! Videotaping No Videotaping of routines or parts of routines are allowed until after the first competition. Our kids work very hard and we don’t want our product to be public until we are prepared for the first competition. This includes posting stunts and tumbling passes to Facebook. Competitions ARE REQUIRED - Attendance will be taken at meeting check in time. Once checking in all members are required to stay with the team. All teams are required to sit together as a gym at all events. Family and friends are encouraged to sit with the gym as well to support all of our teams. It is required to be at every team’s performance for support. It is required for all members of Koach to be present at all award ceremonies as a team. Some situations will allow for early dismissal due to time and travel of events. Uniform Presentation When in uniform you are representing Koach Allstars and you are to wear the uniform as intended. Do not wear flip flops, ugg boots while in uniform however it is okay to wear while in warm ups. No bra straps or underwear should ever be seen while in uniform! Senior teams in crop tops are to be covered up at all times except during warm ups and while performing. (This is a USASF rule for all gyms across the national) No alterations or embellishments are to be added to the uniform unless approved by Coach Ashley. Travel Travel will be the sole responsibility of the families to get their son / daughter to practice, competition, or event. Bus transportation will NOT be a part of Koach Allstars. We feel it is best for families to take that responsibility. Travel may be local, state, or nationally and it is your responsibility to have them on time, as the team is dependent on every member. We hope you will respect the team in this aspect. Sportsmanship Teaching good teamwork and value to our athletes is very important to team unity and our program. We expect ALL members of Koach to treat others with respect and represent Koach Allstars to the best of their ability both in and out of the gym. This includes both the staff, athlete, and or parents as well as public social media. Koach will strive to be the gym known for good sportsmanship. This includes wishing all teams’ good luck and treating your own teammates with respect. When wearing Koach Allstars you are not only representing yourself but the name of the gym. Do not show any behavior that may jeopardize the Koach Image. Failure to do so may result in removal from the program. Parents Role A parent’s role in the sport of cheerleading is unique. We ask that you are not only your athlete’s biggest cheerleader but also support their entire team. The will help to boost everyone’s confidence and camaraderie. We will have opportunities for team parents to bring snacks, host events, or create opportunities for fun outings. When at the gym please keep negative comments to yourself. Also when at the gym please allow the coaching staff to coach your son or daughter. If your athlete is practicing at home please make sure that it is in a safe environment and only working on skills or drills they have mastered at the gym. We do not encourage “back yard tumbling” meaning teaching yourself new skills. Often times the fundamentals are not there making it harder to master the correct technique or harder to retrain your body when the time comes. Discipline Koach Allstars is a team sport. It is very important all team members are at practice. Please do not use missing practice as a punishment. You must remember that allstar cheerleading is a team sport and when even one athlete is missing several parts of the routine cannot be practiced. Also if a child gets their phone taken away it will be the parent’s responsibility to check Facebook and email on their behalf regarding the Koach team as these are our main forms of communication. Parking Our facility does have limited parking. Please make sure you are parking in an actual parking space or along the cul-de-sac not blocking any of the driveways. Please no double deep parking. Please do not block any of the other businesses garage doors or use their parking directly in front of their building. Please do not cover the dirt driveway on the North East corner of the building. Parades/Community Events Koach will participate in parades during the summer and community events throughout the year. We plan to participate in the following, Urbandale 4th of July Parade & Ankeny Summerfest Parade July 12th. Cancelations/Closings Koach will close for major holidays. If Ankeny schools close due to weather the gym will be closed. Please watch the website, Facebook page and email for other weather related closings. Closing will not be made up. 2014-2015 Planned Closings May 26th – Closed Memorial Day June 2nd – June 6th – Closed for choreography camp. July 4th – Closed Holiday (Koach will be in the Urbandale parade.) July 4th – July 11th – Summer Break August 14th – Closed for First day of Ankeny Schools September 1st – Closed Labor Day November 26th – November 28th Closed for Thanksgiving December 22nd – December 26th Closed for Christmas Break December 31st & January 1st- Closed for New Years March 16th – March 20th – Spring Break Fundraising We will try to provide opportunities to fundraise for both the gym and for individuals who may need assistance on cost. Please see the office for more information. Communication Koach will use technology as its main source of communication. This includes Facebook. We ask that all families create a Facebook account and friend KoachAllstars Cheerteamsandtumbling. Each team will have a private group made for private information such as hotel and practice changes. This is something that needs to be checked regularly. We will also use email and text messages regularly. We will use our website www.koachallstars.com for downloaded forms and update information. Koach Allstars Handbook Acceptance Statement: This must be read, signed, and turned in before athlete will be allowed to participate in practice at Koach Allstars. It is imperative that both cheerleaders and their parents / guardian understand the Koach Allstars Handbook. Please indicate that you have read and understand with the information by signing and dating the form below. My child, ________________________has my permission to be in the Koach Allstars program. I understand that he / she must abide by the rules and regulations set forth by Koach Allstars, and be present for all practices, camp, competitions, and events. I understand that I am responsible for all cost involved with Koach Allstars. I hereby state that I have read and understand the contents of Koach Allstars Handbook. I acknowledge that there are and will be consequences if the guidelines and rules are not abided by. I will represent Koach Allstars to the greatest level of character expected. This will include both athlete and parents while in the gym, out of the gym, as well as social media. --------------------------------------------------------------------------------------------------------- Cheerleader (if old enough to understand) Print Name______________________ Signature_________________ Parent / Guardian Print Name__________________ Signature______________ ____ Date___________ ________________________________ ________ Date____________ ____________________________________
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