JERSEY TAP FEST

PERSONAL INFORMATION

Participant’s Name:

Participant’s E-mail:

Participant’s Age and Birth Date:

Parent/Guardian’s Name (if under 18):

Parent/Guardian’s E-mail:

Mailing Address:

Preferred Telephone #:

Studio Name:

Studio Address:

How did you hear about us?

**Please e-mail to:

JerseyTapFest@yahoo.com

**Or Fax to: 908-766-1319

PAYMENT

MASTER CLASSES:

     (  ) First Class: $30

     (  ) Additional Classes: __ x $25 = $___

     (  ) Early Bird Classes: __ x $20 = $___

EVENTS: (1 Ticket for participant included in packages)

     (  ) Jam: __ x $10 = $___

     (  ) Student Showcase: __ x $10 = $___

     (  ) Panel Discussion: __ x $10 = $___

     (  ) History Class: __ x $10 = $___

PACKAGES:

     (  ) Youth Package: $195

     (  ) Intermediate Package: $310

     (  ) Advanced Package: $310

     (  ) Ultimate Package: $325

SUBTOTAL: $______

REGITRATION FEE: $20

TOTAL BALANCE DUE: $_______

Credit Card: (MC & VISA)

Card ____________________________

Expiration Date: __________

Signature: ________________________

(You must be 18 years or older to sign this form)

I have read all registration instructions and the cancellation policy. I hereby release Jersey Tap Fest, Hillary-Marie LLC., all instructors, sponsors, interns and event locations, from any and all claims of liability due to personal injury or loss of property  which I (or my child) may sustain as a result of participating in any activity connected with Jersey Tap Fest. I release my image for filming and photographing by Jersey Tap Fest.

X_____________________________ Date:______