Select one:  Region 1 through 9

Region # 1  Region # 2  Region # 3  Region # 4  Region # 5  Region # 6  Region # 7  Region # 8  Region # 9

The Name of the Club:

Type of Club
Select more than one if it applies
(Hold down Control to Select or Deselect disjoint items.)

Mainstream Club  Beginner Club Plus Club  A Club  C Club  Contra Club  Clogging Club  Pre Rounds  Pre Rounds Highest level  Pre Rounds Lowest Level  One Round Between Tips  Two Rounds Between Tips  Rounds Phase 1  Rounds Phase 2  Rounds Phase 3  Rounds Phase 4  Rounds Phase 5  Rounds Phase 6 

Hall Name:

Hall's Physical Address: { not Mailing }

Start of Season

End of Season

Select Start time of {Pre Rounds if applicable}  { If on the 1/4 hrs / early if necessary}
1:00  1:30  2:00  2:30  3:00  3:30  4:00  4:30  5:00  5:30  6:00  6:30  7:00  7:30  8:00  8:30  9:00  9:30  10:00  10:30 11:00  11:30  12:00  12:30

Select AM or PM
AM  PM 

Day of the week

Monday  Tuesday  Wednesday  Thursday  Friday  Saturday  Sunday

When during the Season

Every Week  1 & 2  1 & 3  1 & 4  2 & 3  2 & 4  3 & 4  3 & 5  5 

Who is the Club Caller & Taw:

Who is the Club Cuer & Taw:

Who is the Club Contact Name :

Contact Phone # Area Code
250  604 509  206
Contact Phone # is :

What is your E-Mail Address :

What is your Full Name:

Let your E-Mail address Stand for this Club
Yes I want to be the Liaison Officer  No I don't want to be the Liaison Officer

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