Saturday, July 15, 2017

(Please type your information and print)

Send to:  Conchi Madson, 3749 Davenant Avenue, Cincinnati, Ohio  45213

Name:_________________________________________ Dance Name______________________________

Address________________________________________ City:________________  Zip Code____________

Phone__________________________ E-Mail Address___________________________________________


              Fee to perform at the show  $15.00  per person         #            $_______
                  (attendace to show free)
              Evening show -   Adults $18.00                                #            $_______

                  Children under 12   $10.00                                  #             $_______
                            Under 5 years  - Free

                   Concert Video by Tony: $35.00 shipping included        #                 $_______
                                                                                                                 Total $___________
                                                                                                                                                                Please Note:       No refunds unless event is canceled!                                                   

Send Check to:  Conchi Madson,    3749 Davenant Avenue, Cincinnati, Ohio 45213

Conchi and Mayerson JCC cannot assume any liability or responsibility for loss of property or injuries incurred by you or others while you are exhibiting, entertaining, performing or otherwise participating in this event.  By agreeing to participate, you assume the risk and responsibility for injuries.