EXHIBITION PERFORMANCE VENUE Friday, June 20, 2008 Arts Bank Theater 320 S. Broad (Broad & South Streets) Philadelphia, PA. 19102 FINAL MAIL -IN DEADLINE IS June 10, 2008
First Name: *
Last Name: *
Address: *
City: *
State: *
Postal Code: *
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E-Mail:
Day Phone:
Payment Method:
Check 534 S. 56th Street, 1st Floor Rear
Philadelphia, PA 19143
Check Number
PayPal
Enter your age:
Name of School:
Submit Money Order To: New LEJA 534 south 56th Street - 1st fl. Philadelphia, PA. 19143 - (215) 747-5352 NO Refunds
Name of Performance Piece:
Time:
Fees
Per Person Fees are as follows -
Solo(s) $10. Duo(s) and Trio(s) $10. Group(s) $10.
Enter Quantity Below:
Solo
Duet (Price is per person)
Trio (Price is per person)
Group (Price is per person)
Name of Performer/Performers: (A signed registration form must be submitted for each performer)
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I hereby agree that I am participating in the Philly Tap Challenge of my own free will and will abide by all rules and regulations relating to the event. I hereby release LEJA, PCBC the directors, their agents, servants and any employees of the Philly Tap Challenge and the Arts Bank Theater upon which the event is being conducted, from all claims for damages including but not limited to loss of property, accident or injury during or in connection with the said event. I have read and understand this agreement; my signature indicates my agreement to be bound by the above.
Signed (Parent or legal Guardian if under 18 yrs. of age)
Ads and Contributions Circle of Friends
Ads and Circle of Friends Contributions are tax deductible through Philadelphia Civic Ballet Company - The Oldest Dance Company in the Commonwealth of PA.
