CHICAGO DANCE CLUB MEMBERSHIP
(PLEASE PRINT)
NAME:___________________________________________________________________________
ADDRESS:________________________________________________________________________
CITY _________________________________________ STATE: _________ ZIP:_________________
PHONE: (HOME)_____________________________________ (CELL)__________________________
E-MAIL ADDRESS:____________________________________________________________________
(FOR CLUB USE ONLY)
BIRTHDAY: ____________/_______ (MONTH & DAY ONLY)
CASH: _____________ CHECK #______________ OTHER:_______________________
INTERESTED IN WORKING AT DANCES: YES_____ NO_______
1-YEAR MEMBERSHIP - $25.00
PLEASE SEND COMPLETED FORM & CHECK OR MONEY ORDER (DO NOT SEND CASH)
PAYABLE TO: CHICAGO DANCE CLUB
C/O : PHIL BIANCO
405 NORTH HAMLIN AVENUE
PARK RIDGE, IL 60068
I AGREE TO BECOME A MEMBER OF CHICAGO DANCE CLUB AND TO ADHERE TO ALL CLUB RULES AND REGULATIONS AS SET FORTH IN OUR BY LAWS. I ALSO DO NOT HOLD THE CHICAGO DANCE CLUB OR ANY OF IT’S MEMBERS OR FACILITIES LIABLE FOR ANY INJURIES OR MISHAPS THAT MAY OCCUR WHILE I AM ATTENDING THEIR FUNCTIONS.
X_________________________________________________DATE:____/____/____
CHICAGO DANCE CLUB HAS THE RIGHT TO REFUSE ADMISSION TO ANYONE .
