Seminar(s) Online Registration - CD * DVD *
Tax Deductible Donation

This is an online Registration Form for the Dancing For The Dream Senior Health Charity Seminars. We also offer CD/DVD product sales that help us raise working capital to keep our charity operating. Your Fee for a seminar 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 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 mail 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: We TAKE American Express. Enter #
Card number:
Expiration date: CVC # What's This
                                                               AMEX uses 4 Digits on Front instead of 3 digits on back
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 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
  2015 / 2016 Season Seminars and Bootscooter Dance Camps
Orlando, FLORIDA
The Renaissance Senior Center
Friday April
7th, 2017
$50 Friday 2pm-8pm
Workshop & Dance
Rocklin, CALIFORNIA
Clarke Dominguez Gym
April
29th, 2017
$55 Saturday Only
Lubbock, TEXAS
Lubbock Federated Square Dance Center
September
9th, 2017
$50 Saturday Only
Lubbock, TEXAS
Lubbock Federated Square Dance Center
September
8th-9th, 2017
Friday Night $10
Saturday $50 = $60
Blairsville, GEORGIA
Blairsville Civic Center
September 2017
Exact date TBA
$50 Saturday Only  
Ft Myers, FLORIDA
Siesta Bay Resort
January
13th, 2018
$55 Saturday Only
Ft Myers, FLORIDA
Siesta Bay Resort
January
13-14, 2018
$65 Full Weekend
Lunch on Saturday
Myrtle Beach, SOUTH CAROLINA
Myrtle Beach Base Center Large Ballroom
February
17th,2018
$55 Saturday Only
Myrtle Beach, SOUTH CAROLINA
Myrtle Beach Base Center Large Ballroom
February
16-17-18,2018
$65 Full Weekend
Lunch on Saturday
Scooter Lee's New Gospel CD
"Joy's Gonna Come In The Morning"
$12.99
plus $4 Shipping USA and $7
International - Dances Inc
CD will be shipped
with Dance Sheets
Dancing For The Dream Charity - National Nonprofit
"The Message is FREE, taking that message on the
road is NOT." Please Donate.
100% Tax Deductible
      $10   $20    $30
   $50
   $100
Other Amount
DONATED
$
Newbie Line Dancer Special w/Reference DVD
For New
Line Dancers
2 DVD's & Music CD
$39.95
plus S&H
Sing A New Song Gospel Dance CD
$12 & $4 US / $6 International
CD will be shipped
with Dance Sheets
Starter Series Combo CD/DVD
$29.95 plus S&H (USA S&H $9.98)
Price $29.95
plus Shipping
16 Dances / 16 Songs
Guaranteed to get you out on the dance floor!

Ultimate Reference DVD
Instructor: Jo Thompson Szymanski
For New Line Dancers & Instructors

70 of the Most Common Steps Used in Line Dancing Today
$19.95 plus $7 Shipping
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 or product order 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're ordering a Scooter Lee Product, we don't need the below information. Just click SUBMIT at the bottom of the page. If you are registering for a Line Dance Seminar, we need the information below due to our insurance. We are a 501c3 Nonprofit Charity      
                                                                                            
    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:
s
  Depression   High Blood Pressure    High Cholesterol     Diabetes

Have you had:
d
  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:
s

  Lower Back Pain      Osteoarthritis       Arthritis         Diabetes

Take Medication for:
s
  Depression   High Blood Pressure    High Cholesterol     Diabetes

Have you had:
d
  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:
s
  Depression    High Blood Pressure    High Cholesterol     Diabetes

Have you had:
d
  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:
f

  Lower Back Pain      Osteoarthritis         Arthritis     Diabetes  

Take Medication for:
s
  Depression   High Blood Pressure    High Cholesterol    Diabetes

Have you had:
d
  Hip Replacement  Back Surgery Knee Replacement  Heart Surgery





A Confirmation Letter will be sent via US Mail 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.

We are a National Nonprofit Senior Health Charity that uses Line Dance as it's chosen form of exercise. We hold the same
license as The American Heart Association, The Alzheimer's Foundation and The Arthritis Institute for Adults.

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!