TAC Teacher Candidate Course  REGISTRATION FORM

August 1 – 15, 2004.     St. Jerome’s University, Waterloo, Ontario Canada

REGISTRATION DEADLINE March 1st, 2004

 

Name:

 

 

(please print clearly)

 

Name as it is to appear on your nametag - as above or:

 

 

Mailing Address:

 

 

 

Prov/State:

 

Country:

                                                        

Postal Code:

 

Telephone:

day

(          )

evening:

 

Fax:

fax:

(          )

Email:

 

 

Please circle as appropriate:

I am:

Male

Female

My age group is (years)

18-30

31-45

46-60

61+

I have been dancing for (years)

4-6

7-10

10+

 

My current teacher is:

 

I hold a Preliminary Test Pass – where obtained:

 

When:

 

I have previously attempted:

Preliminary Test

 

Teacher’s Certificate

 

         Where:

 

When:

 

A confidential statement has been forwarded to Rebecca Roman by:

 

 

Name of referring person/teacher

I am a current TAC member

Yes

No

My special dietary or other requirements are:

 

Person to contact in case of emergency:

Name 

 

Phone #

(          )

 

Standard accommodation is shared twin:

 

 

My preferred room-mate is:

 

Single accommodation is very limited.  If possible, I prefer single accommodation

With a surcharge of      $110 CDN    $75 US

REGISTRATION FEES

(cheques will not be processed until acceptance confirmed)

CDN

US

Full 14 day course

$1350

$1025

AGM Weekend reception, banquet and ball (Sat. Aug 7th)

$30

$20

PAYMENT

I am enclosing

Full payment

$1350 CDN

$1025 US

 

Deposit (per person)

  $100 CDN

    $75 US

I am enclosing post dated cheques to pay the balance on or before June 1, 2004

date

 

amount

 

CDN     US

date

 

amount

 

CDN     US

Overseas candidates only may pay by VISA credit card:

Card #

 

expiry

 

Cardholder’s Signature

 

Please make cheques / money orders / bank drafts payable to:  TAC Summer School

and send with completed registration form to:

Registration Forms:

 

Marie Ziccarelli

TAC Candidate/Summer School Registrar

206 Warsaw Street

Lackawanna, NY

14218, USA

email:  zmrezz@aol.com

Confidential Statements:

 

Rebecca Roman

TAC Candidate/Summer School Director

295 Woodward Avenue

Buffalo, NY

14214, USA

email:  gaudete@buffnet.net

SILVER JUBILEE SCHOLARSHIP FUND

I wish to apply for assistance to attend TAC Teacher Candidate Classes:

YES

NO

NB – Deadline for Scholarship applications is May 1st, 2004

(Application forms and Guidelines available from Rebecca Roman or www.tac-rscds.org )
APPLICATION DEADLINE FOR CANDIDATE COURSES:  March 1, 2004