Dancing For The Dream, the health and exercise site for senior citizens.

Dancing For The Dream® Event Registration

This is an online Registration Form for the Dancing For The Dream Senior Health
Charity Seminars. Your Fee is a donation for senior health awareness and TAX DEDUCTIBLE. Our seminars gather research on the benefits on line dancing for Active Adults. All questions must be answered. As a National Health Nonprofit,
we require all information due to insurance purposes including your date of birth. Your personal info and credit card information are secure with The D4D Corporation.

There are two ways to use this form:

(1) Use the PRINT button on your browser to print the form and fax it to
404-634-1726, or mail it to:

DANCING FOR THE DREAM, INC
1971 Variations Drive NE - ATLANTA, GA 30329-1038

(2) Fill out the form online, press the SUBMIT button at the bottom of the form, and it will be transmitted across the secure server. Please give us your EXACT mailing address to receive confirmation including your space or lot number if applicable. If it is a summer or temporary address, then please provide your PERMANENT Address for our files.

BILLING INFORMATION:

E-Mail Address:	(Required if submitted online)

Name:

Billing Address:

City:

State:

Zip or Postal Code:

Country:

Telephone Number:

Credit Card Information:

Cardholder name:

Card type:

Card number:

Expiration date:

CVC # What's This

Signature:

(Not required if submitted online)

Sending this registration online does not require a signature. In sending this online it is understood that you are releasing The Dancing For The Dream Charity and Existing Seminar Venue from any responsibility of "out of normal" accidents. We take every precaution to provide you a safe atmosphere for instruction and line dancing. Thank you.

Are you a(an):

Dancer	DJ	Instructor	Teach Seniors	Active Adult
(Check all that apply above and below)				(over 50)

How did you hear about this Website:
Website    Card in Mail   Your Instructor Search Engine
Magazine    Attended a D4D Event                (Check all that apply.)

Venue where you dance, teach and/or DJ:

Current Dancing For The Dream® Events:
NOTE: Please enter the number of people you are registering for the specified event below. Only 1 event registration at a time. Return to this page for additional registrations. Price is per registrant.

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EVENT	DATES	PRICE	TICKET QTY
2008 SEASON SEMINARS
Glen Burnie Elks Club Severn, MARYLAND	May 3rd	$40 Before May 1st
The Savannah Center The Villages, FLORIDA	May 25th/26th	E-mail Janemarie Dorsey at countrydancer@comcast.net
Pieters Family Life Center Rochester, NEW YORK	June 7th	$40 Before June 1st
The Shepherds Center Spartanburg, SC	August 16th	$40 Before August 10th
Colorado Senior Games Greeley, COLORADO	June 21st and 22nd	Contact the games directly - 970.350.9438
Ravenna Eckstein Center Seattle, WASHINGTON	September 13th	$40 Before September 10th
Siesta Bay Resort Ft Myers, FLORIDA	November 22nd	$40 Before November 15th

The Newbie Special	For New Line Dancers	2 DVD's & 2 CD's for $35

Registrant Information: If your information is same as the credit card info, just give us your date of birth and how long you've been linedancing. This will save YOU time. Your registration will not be processed without this information. Your info is secure and kept private and used only by our corporation. If you do not put how long you've been dancing, you will be entered as a new line dancer or "Starter".

Registration #1

Name:

Address:

City:         State:

Zip or Postal Code:

Country:

Telephone Number: Date of Birth:

How long have you line danced?     years    months     days

(Check all that apply below)

Do you have:

  Lower Back Pain     Osteoarthritis      Arthritis   Diabetes

Take Medication for:

  Depression   High Blood Pressure    High Cholesterol   Diabetes

Have you had:

  Hip Replacement Back Surgery Knee Replacement Heart Surgery

Registration #2

Name:

Address:

City:         State:

Zip or Postal Code:

Country:

Telephone Number:     Date of Birth:

How long have you line danced?     years    months     days

(Check all that apply below)

Do you have:

  Lower Back Pain      Osteoarthritis       Arthritis    Diabetes

Take Medication for:

  Depression   High Blood Pressure    High Cholesterol    Diabetes

Have you had:

  Hip Replacement Back Surgery Knee Replacement Heart Surgery

Registration #3

Name:

Address:

City:         State:

Zip or Postal Code:

Country:

Telephone Number:     Date of Birth:

How long have you line danced?     years    months     days

(Check all that apply below)

Do you have:

  Lower Back Pain     Osteoarthritis       Arthritis   Diabetes

Take Medication for:

  Depression    High Blood Pressure    High Cholesterol   Diabetes

Have you had:

  Hip Replacement Back Surgery Knee Replacement Heart Surgery

Registration #4

Name:

Address:

City:         State:

Zip or Postal Code:

Country:

Telephone Number:     Date of Birth:

How long have you line danced?     years    months     days

(Check all that apply below)

Do you have:

  Lower Back Pain      Osteoarthritis         Arthritis   Diabetes

Take Medication for:

  Depression   High Blood Pressure    High Cholesterol Diabetes

Have you had:

  Hip Replacement Back Surgery Knee Replacement Heart Surgery

A Confirmation Letter will be sent to the address you've registered with; once your registration has been processed. This will be your ticket and your tax receipt. You must bring this confirmation with you the day or seminar. If there's a problem with your credit card, we will contact you via telephone and/or e-mail.

Cancellation Policy: $30 of your $40 will be refunded with cancellation. $10 is kept for administrative costs. No refunds allowed for "No Shows". If you call "day before and day of" seminar it is considered a "no show". You may sell or give away your ticket. You are supporting a National Nonprofit Senior Health Charity. A 501(c) 3 Georgia Registered Charity. Our Tax ID 57 115 5415

We're adding years to your life and life to your years!