Ultimate Starz Dance Championships & Convention Registration

Ultimate Starz Dance Championships & Convention Registration (Please COMPLETELY feel out a separate sheet for each entry. Please copy form if needed.) Studio/School/Organization:______Address:______Phone:__(_____)______-______E-mail:______Instructor(s)/Choreographer(s)/Director(s):______Routine Name:______~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~  Regional Category Registration (circle one) Accapella Group Clogging Exhibition Lyrical Production Ballet/Pointe Clogging Line Modeling (Casual) Song and Dance Character Clogging Moving Line Modeling (Formal) Student Cheer/Dance/Pom/Acro Clogging Traditional Line Modern Choreography Clogging Contemporary Musical Theatre Tap (Percussive) Clogging Freestyle Solo Hip Hop Open Clogging Freestyle Team Jazz Photogenic ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~  ” 2013-2014 Mr & Miss Ultimate Starz Dance” (check if applies) ___This solo dancer would like to be considered to be a 2013-2014 National finalist! ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~  Age Divisions (circle one) Tiny Tot (4 & under) Petite (9-10) Senior (16-18) Mini (5-6) Pre-Teen (11-12) Young Adult (19-29) Little Folks (7-8) Teen (13-15) Adult (30 & up) _____ACTUAL AGE ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~  Please circle the appropriate level: (Please be honest!) Rising Starz Shooting Starz Shining Starz ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~  CHAMPIONSHIPS and FALL CONVENTION Fees  (Fee per dancer!)  Competition Registration  ~EVENT LOCATION:______(Please list dancer’(s) names on next page!) Solo Routine ...... $50.00 x ____ = ______Duo/Duet/Trio ...... $30.00 x ____ = ______Small Group (4-8 dancers) ...... $22.00 x ____ = ______Large Group (9 or more dancers)...... $20.00 x ____ = ______Production (10 or more dancers) ...... $22.00 x ____ = ______Photogenic (per photo) ...... $25.00 x ____ = ______Clogging Solo Freestyle ...... $15.00 x ____ = ______TOTAL AMOUNT ENCLOSED = ______------ 2012 Fall Convention Registration  Note: 2012 Pre-Registered Workshop Dancer Fee Includes a Convention T-shirt & Pizza Lunch! Workshop Dancer (by 10-13-12) ...... $45.00 x ____ = ______Workshop Dancer w/out lunch (by 10-13-12) . . .. $42.00 x ____ = ______Workshop Dancer after deadline or at door . . . . $48.00 x ____ = ______Workshop Spectator ...... $10.00 x ____ = ______Video Handler (Must be a registered dancer!) . . $50.00 x ____ = ______TOTAL AMOUNT ENCLOSED = ______T-shirt sizes available: (Youth S-L) or (Adult S-XXL)…(Please list t-shirt size with names on next page!) (Note: ONLY Pre-Registered workshop dancers receive free t-shirt and lunch!) NOTE: Please be sure to list each dancer in each routine as we put their names in the program book. Also, please make a separate MASTER LIST of ALL GROUP dancers as each one of them will receive a special participation trophy! ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ROUTINE NAME:______

Age as of event T-shirt size Participants Name (Please print neatly!) date DOB (Convention only!) 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. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ NOTE: “Ultimate Starz Dance Productions” and its staff and the event facility and its staff will not be held responsible for loss, theft, and/or injury. I here by understand this statement. ~Dancer’s/Director’s/Teacher’s/Representative’s Signature: ______~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ Mail Registration forms & make cashiers checks, studio checks, or money orders (only) to:

Monika & Patrick Priddy-USDP P.O. Box 212, Westfield, NC 27053 Phone: (336) 351-4012 or E-mail: [email protected] Website: www.ultimatestarzonline.com