Country Dance * New York, Inc.

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Country Dance * New York, Inc

Playford Ball - Saturday, April 5, 2003

REGISTRATION FORM

Name(s) as it(they)
will appear on nametag 		_________________________ _________________________
Address _________________________

_________________________

_________________________ 		_________________________

_________________________

_________________________
Telephone _________________________ _________________________
Email _________________________ _________________________


Membership Categories
Individual $ 25
Couple at same address $ 40
Contributor $ 50
Supporter $ 100
Angel $ 150
     
Remittance
Please reserve _____ spaces at $35 per person. $ _____
Contribution to Playford Ball Fund $ _____
Membership fee to join CD*NY.
(good through August 31, 2003) 		$ _____
Total:
$ _____


I am interested in a partial work scholarship: _____