NEW [ ] $22.00 PER PERSON RENEWAL [ ] $20.00 PER PERSON

(Make Checks Payable to: Cactus Corners Dance Club)

Please Print! Date:

Last Name: First Name:

Address:

City: Zip Code:

Home Phone:( ) Birthday Month:

E-MAIL:

Associate Member: Birthday Month:

REMEMBER: UPDATE ALL INFORMATION AND INCLUDE YOUR BIRTHDAY MONTH!

I, the undersigned, hereby release and discharge the Cactus Corners Dance Club, officers, advisors, members, employee’s agents and representatives from all liability arising from or in connection with club activities.

Signature of General Member:

Signature of Associate Member:

MAIL APPLICATION TO: CACTUS CORNERS DANCE CLUB

P.O. Box 10551, Pleasanton, CA 94588

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FOR CLUB USE ONLY:

Paid: Check [ ] # Cash [ ] AMOUNT: $