Canadian Open Square, Step Dancing

Canadian Open Square, Step Dancing & Clogging Competition 2017 Fiddle Entry Form Please enclose entry fee

Name of Fiddler: ______City/Town: ______

Contact Name: ______

Address of Contact: ______

Postal Code: ______Phone number: ______

Email address: ______

Make prize winning cheque payable to: ______

Entry Fee Names and Ages of Fiddler

Under 18 years …….………….$5.00 (……) ______(under 18 years by June 30th;) Date of Birth:

______18 Years and Over ……………..$5.00 (……) (18 years by June 30th; ) ______

______

Total amount of entry fee enclosed: ______

List any fiddler competing in other classes: ______

______Make cheques payable to Dundalk Dance Association

I agree that group and/or individual photography may include the image of the participant(s) named below for promotional purposes only.

Signed:______Date:______

Send entries to: Dundalk Dance Association, Office Use Only P. O. Box 352, Dundalk, Ontario N0C 1B0 □ Payment Received Phone: (519 )923-3406 □ Confirmation Sent Email:[email protected] □ Program Addition www.facebook.com/dundalkdanceassociation