Dancing For The Dream | Health and Excercise for Senior Citizens

BILLING INFORMATION:

E-Mail Address:	(Required if submitted online)

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Sending this registration online does not require a signature. In sending this online it is understood that you are releasing The Dancing For The Dream Charity and Existing Seminar Venue from any responsibility of "out of normal" accidents. We take every precaution to provide you a safe atmosphere for instruction and line dancing. Thank you.

Are you a(an):

Dancer	DJ	Instructor	Teach Seniors	Active Adult (over 50)
(Check all that apply above and below)

How did you hear about this Website:
Website Card in Mail Your Instructor Search Engine Magazine Attended a D4D Event (Check all that apply.)

Place where you dance or teach :

Current Dancing For The Dream Seminars NOTE: Please enter the number of people you are registering for the specified seminar below.
EVENT	DATES	PRICE	TICKET QTY
2009/2010 SEASON SEMINARS
Rockaway, NJ 2009 Rockaway Dance Hall	April 18th, 2009	$40 Before April 15th, 2009
Rocklin, CA 2009 Clarke Dominguez Gym	May 9th, 2009	$40 Before May 6th, 2009	Sold Out
Bootscooter Line Dance Camp 2009 The Sterling Hotel Dallas, TEXAS	May 22, 23, 24 Memorial Day Weekend	Currently the page for this weekend will have boxes for room and dinner choices. (3 Days) $50 Deposit required to hold room.	Order Form For Brochure 1-800-531-4379
Spartanburg, SOUTH CAROLINA The Shepherds Center 2009	August 15th, 2009	$40 Before August 13th, 2009
Harrison Twp, MICHIGAN Thomas Welsh Activity Center	October 3rd, 2009	$40 Before October 1st, 2009
Ft Myers, FLORIDA 2010 Siesta Bay Resort	January 9th, 2010	$45 Before January 7th, 2010
Mesa, ARIZONA 2010 Viewpoint Golf Resort	February 13th, 2010	$45 Before February 10th, 2010
Home To Louisiana Scooter's New CD	Order Matching DVD	Cost is $12 plus $4 Shipping 15 songs for all levels of line dance
Home To Louisiana DVD - 15 Dances	Beginner to Intermediate	Jo Thompson - Your Instructor DVD $16 plus $7 Shipping
Home To Louisiana CD & DVD Combo	Plus FREE Christmas CD	$28 plus $10 Shipping
The Newbie Special	For New Line Dancers	2 DVD's & 2 CD's for $35
Gospel Dance CD	All levels of line dance	Cost is $12 plus$4 Shipping
Ultimate Reference DVD Instructor: Jo Thompson Szymanski For New Line Dancers & Instructors	70 of the Most Common Steps Used in Line Dancing Today	Cost is $19.95 plus $7 Shipping
Registrant Information: If your information is same as the credit card info, just give us your date of birth and how long you've been linedancing. This will save YOU time. Your registration will not be processed without this information. Your info is secure and kept private and used only by our corporation. If you do not put how long you've been dancing, you will be entered as a new line dancer or "Starter". If you are only ordering the CD, we don't need anymore information.

Registration #1

Name:

Address:

City: State:

Zip or Postal Code:

Country:

Telephone Number: Date of Birth:

How long have you line danced? years months days

(Check all that apply below)

Do you have:

Lower Back Pain Osteoarthritis Arthritis Diabetes

Take Medication for:

Depression High Blood Pressure High Cholesterol Diabetes

Have you had:

Hip Replacement Back Surgery Knee Replacement Heart Surgery

Registration #2

Name:

Address:

City:     State:

Zip or Postal Code:

Country:

Telephone Number:     Date of Birth:

How long have you line danced?     years    months     days

(Check all that apply below)

Do you have:

Lower Back Pain Osteoarthritis Arthritis Diabetes

Take Medication for:

Depression High Blood Pressure High Cholesterol Diabetes

Have you had:

Hip Replacement Back Surgery Knee Replacement Heart Surgery

Registration #3

Name:

Address:

City:     State:

Zip or Postal Code:

Country:

Telephone Number:     Date of Birth:

How long have you line danced?     years    months     days

(Check all that apply below)

Do you have:

Lower Back Pain

Osteoarthritis Arthritis Diabetes

Take Medication for:

Depression High Blood Pressure High Cholesterol Diabetes

Have you had:

Hip Replacement Back Surgery Knee Replacement Heart Surgery

Registration #4

Name:

Address:

City:     State:

Zip or Postal Code:

Country:

Telephone Number:     Date of Birth:

How long have you line danced?     years    months     days

(Check all that apply below)

Do you have:

  Lower Back Pain      Osteoarthritis         Arthritis   Diabetes

Take Medication for:

  Depression   High Blood Pressure    High Cholesterol Diabetes

Have you had:

  Hip Replacement    Back Surgery    Knee Replacement    Heart Surgery

A Confirmation Letter will be sent to the address you've registered with; once your registration has been processed. This will be your ticket and your tax receipt. You must bring this confirmation with you the day or seminar. If there's a problem with your credit card, we will contact you via telephone and/or e-mail.

Cancellation Policy: $30 of your $40 will be refunded with cancellation. $10 is kept for administrative costs. No refunds allowed for "No Shows". If you call "day before and day of" seminar it is considered a "no show". You may sell or give away your ticket. You are supporting a National Nonprofit Senior Health Charity. A 501(c) 3 Georgia Registered Charity. Our Tax ID 57 115 5415

We're adding years to your life and life to your years!