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

Seminar(s) Online 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 is TAX DEDUCTIBLE. Our seminars gather research on the benefits on line dancing for Active Adults and how it can enhance the aging process. All questions must be answered. As a National Health Nonprofit, we require all informaton 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.)

Place where you dance or teach :

Current Dancing For The Dream Seminars
NOTE: Please enter the number of people you are registering for the specified seminar below.

EVENT	DATES	PRICE	TICKET QTY
2010 SEASON SEMINARS
Villa Rica, GEORGIA Villa Rica Civic Center	April 10th, 2010	$45 Before April 9th, 2010
Rockaway, NEW JERSEY Let's Dance Rockaway Venue	April 17th, 2010	$45 Before April 15th, 2010
New Kensington, PENN The Alle Kiski Senior Center	May 1st, 2010	$45 Before April 29th, 2010
Rocklin, CALIFORNIA Clarke Dominguez Gym	May 15th, 2010	$45 Before May 13th, 2010
Spartanburg, SC The Shepherds Center	August TBA
Harrison Twp, MICHIGAN Thomas Welsh Center	October 2nd, 2010	$45 Before September 30th, 2010
Seattle, WASHINGTON Dave's Dance Barn	October 23rd, 2010	$45 Before October 21st, 2010
Ft Myers, FLORIDA 2011 Siesta Bay Resort	January 15th, 2011	$45 Before January 13th, 2011
"Home To Louisiana" Scooter's New CD	Order Matching DVD	Cost is $12 plus $4 Shipping 15 songs for all levels of line dance
Home To Louisiana DVD 15 Line Dances	Beginner to Intermediate	Jo Thompson - Your Instructor DVD $19.95 plus $7 S&H
Home To Louisiana CD & DVD Combo	Jo Thompson is Instructor	$28 plus $10 Shipping
The Newbie Special	For New Line Dancers	2 DVD's & 2 CD's for $35
Gospel Dance CD	All levels of line dance	Cost is $12 plus$4 Shipping
Ultimate Reference DVD Instructor: Jo Thompson Szymanski For New Line Dancers & Instructors	70 of the Most Common Steps Used in Line Dancing Today	Cost is $19.95 plus $7 Shipping

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". If you are only ordering the CD, we don't need anymore information.

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 $45 will be refunded with cancellation. $15 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!