R E G I S T R A T I O N     F O R M

Date of Birth:__________________________________________________________     SEX:                <Male>             <Female>

Address:__________________________________________________________________________________________________________

City:______________________________________________________ State:__________________________________________________

ZIP Code:__________________________________________________

Home Telephone#:_______________________________________________________________________________(including area code)

Parent(s) Name:___________________________________________________________________________________________________
                                          Last                                                               First                                                                 Initial

Alternate Phone #:______________________________________________________________________________ (including area code)

WHICH COMMITTEE ARE YOU INTERESTED IN BEING PART OF:

EXECUTIVE COMMITTEE:     YES     NO

COSTUME COMMITTEE:       YES     NO

PHONING COMMITTEE:         YES    NO

NONE AT THIS TIME:              __________

I hereby understand the rules and regulations of the Kalyna Ukrainian Dance Group and accept them as outlined above.

Parent's Signature: _____________________________________________________Date:_______________________