Pro-Am and Student/Student Country & Western Single Dance Entry Form - Please Print

Teacher: ______Reg. # (CDF / NDCA) ______Female Male Students ______

Studio :______Telephone ______Address: ______City ______Prov./State ______PC/Zip ______Fax______Email: ______Teacher and Student/s must both sign the release form

PROFICIENCY Pro-Am & Student/Student Single Country & Western Events Box Please CHECK/CIRCLE the age category and events you are entering:

Junior: (15 & under), Youth: (16-18), “A”: (19-30), “A1”: (31-40), “A2”: (41-50),

“B1”: (51-60), “B2”: (61-70), “C1”: (71-80), “C2”: (81 & over)

“Proficiency” – Please check the Proficiency Box if you wish to dance for an individual score rather than competing and being ranked against other dancers.

Closed Levels (max 4) Country & Western Dances # Entries

Newcomer______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Pre Bronze______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Interm. Bronze______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Full Bronze______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Pre Silver______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Interm. Silver______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Full Silver______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Pre Gold______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Interm. Gold______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Full Gold______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Gold Advanced______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Open Levels (max 3) # Entries

Open Pre Bronze______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Open Bronze______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Open Pre Silver______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Open Silver______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Open Gold______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Open Gold Advanced______Waltz 2-Step Cha Cha EC Swing WC Swing Polka ______

Open Gold Advanced__ W T FT VW PB CC R SW B MA MER SAM HU WCS SL BC AT W T VW FT QS CC SAM R PD J ______RELEASE FORM -All Teachers & Students-

Please use second page if you have more students.

RELEASE: The undersigned, being fully cognizant of the risks inherent in ballroom dancing and exhibitions, shall hereby:

1. Assume all risks of bodily injury (including death) and property damage inherent in attending this event.

2. Release and hold harmless Can-Am DanceSport Inc, its officers, directors, as well as any person affiliated with, or organizes "The Can-Am DanceSport Gala" ("Event Organizers") from all liability to me, my personal representatives, assigns, heirs, and next of kin, against any claim or cause of action which I, or anyone claiming by, through or under me, may at any time have against those hereby released, arising out of bodily injury (including death) or damage, loss or theft of articles left in changing rooms or ballrooms, suffered by me while attending this event. 3. Consent to use and release of his/her name and likeness to be used in photographs, television filming, and recording of the event used in connection with television broadcast, exhibition, distribution or promotion of the event in any manner and by any means, now or in the future by Can-Am Dancesport Gala, and/or its organizers.

If any person has an objection to being videotaped or the possibility of being seen on these tapes or in any publicity trailers or other use of his or her picture, please notify the organizers of this event in writing thirty days prior to the commencement. Failure to notify will be considered as permission granted.

All persons attending this event, whether as spectators, competitors, officials or guests of the organizer, shall be bound by the Canadian DanceSport Federation and the National Dance Council of Canada rules, and by participating in this event, automatically become obligated to adhere to them. Enter or Print Name Signature