2010-2011 4th Graders Ski And Ride Passport Application Form
Address to Send This Application With Proof Of Grade & $19 payment to:
4th Graders Ski and Ride Passport
PO Box 277 Tully, NY 13159
Fax Number:315-696-6567
Questions? Call: 315-696-6550 or e-mail passport@44free.com
Booklets start shipping in December.
Applications must be postmarked no later than 3/1/2011.
If you pay by check please make payable to Ski Areas of New York, Inc.

Your Name _________________________________________________________________________________

School Name ________________________________________________________________________________

Your Address________________________________________________________________________________

City________________________________________________________________________________________

State/Prov. _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  Zip Code/PC   _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _ 

Telephone Number _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _    _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _ 

E-Mail Address (parent) _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _    _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _ 

Are you a boy? _  _  _  _  _  _  _  Girl? _  _  _  _  _  _  _  _ 

Type of Passport Required? [    ]  STANDARD   /  [    ] Learn To Ski/Snowboard Passport

We fully understand the 4th Graders Ski And Ride Program and agree to follow all conditions listed in the booklet. We understand that any misuse of the passport or lift ticket obtained with the passport will result in us having to give it back. By accepting the Passport, we agree that all resorts, program partners, sponsors and their affiliates, directors, officers and employees are not responsible or have any liability whatsoever for injury, losses or damages of any kind caused by the Passport or resulting from the application for or acceptance, possession or use of Passport.

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Signature of 4th grader (your signature)

OFFICE USE ONLY CK/MO #_____________ ___RC ___BC __NONE __OTHER

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Your parent's signature

Date _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _  _ 
Credit Card Information if not paying by check/money order: ($19 will be charged to your credit card)

Visa/Mastercard/Discover Number: _____________________________________

Expiration Date:____________________

Cardholder Name:____________________________________________________