I. GENERAL INFORMATION
Name of Institution:
Address:
City/State/Zip:	/ ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA 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 PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING	/
Institution's Contact Name/Title:	/
Phone:	(xxx-xxx-xxxx)
Email Address:

II. VARSITY SPIRIT LLC (UCA, NCA, USA, UDA, NDA) EVENT

Is your cheer squad/dance team registered to attend a Varsity Spirit sponsored event or have you attended one in the last 24 months?

Yes No

Event Name:
Event Location:
Event Date:	Expected format: MM/DD/YYYY

III. FOR CHEER SQUADS ONLY - CONFIRMATION OF SAFETY CERTIFIED COACH

Does your squad have an USA Cheer Certified Coach?	Yes No N/A - We are enrolling for coverage for dancers or mascots only.
Name of USA Cheer Certified Coach:

IV. PREMIUM - Minimum annual premium is $435 per enrollment form. Premium is not pro-rated. Please note that premium is based on the number of cheerleaders, dancers and mascots on the team at your peak point of enrollment during the year. Coverage begins at 12:01 am following the time of purchase (July 1, 2022 or thereafter) through June 30, 2023.

	0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 Cheerleaders * $19.95 per Cheerleader =		$
	0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 Dancers * $19.95 per Dancer =		$
	0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Mascots * $19.95 per Mascot =		$

Total Premium Due:

$

Note: If the dance team enrolls separately from the cheer squad a separate minimum premium will apply, so it may be advantageous to enroll both at the same time, when applicable.

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