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1^st Polish Ballroom Dance Championship in the United States

St.Stanislaus Kostka Church 12 Newell Street  Brooklyn, NY 11222

February 7, 2010

Gentelmen: _______________________________________Lady:_______________________________

Studio: _______________________________________________________________________________

Address: ______________________________________________________________________________

City: ________________________________________State:______________ Zip:__________________

Telephone #___________________________________Fax #____________________________________

Email: ________________________________________________________________________________

Dateline  is January  26, 2010

Please circle age, level, and dances.

Couples entering 2 age groups must use 2 forms.

Team Match Joseph’s Dance Studio and other participating studios

Scholarship Events : 1 event  $35, 2 events  $65

Entry fees per couple: 1 event $25, 2 events $45, 3 events $60, 4 events $75.

Total entry fees due: $______________________

Send entry forms, checks, or money orders to:

Joseph’s Dance Studio

356 Mt. Prospect Avenue

Clifton, NJ 07012

917-742 -0553                   973-249-0222               fax 973-249-0224

jdsnynj@optonline.net                    www.josephsdancestudio.com