Fill out the form and
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 This is a late registration (after ).
 Sat. Dance + Sunday Brunch     Sat. Dance Only
First Name:   Last Name: 
 Adult     Youth (12-22)     Child under 12         Subtotal: 
First Name:   Last Name: 
 Adult     Youth (12-22)     Child under 12         Subtotal: 
First Name:   Last Name: 
 Adult     Youth (12-22)     Child under 12         Subtotal: 
First Name:   Last Name: 
 Adult     Youth (12-22)     Child under 12         Subtotal: 
First Name:   Last Name: 
 Adult     Youth (12-22)     Child under 12         Subtotal: 
Total Amount Due: 

Do you want to be on Big Scioty mailing list:  Yes     No.

   Send Flyers by  Regular Mail     eMail
    Send me reminders by eMail before dances.

   Address: 
   City:     State:  Zip: 
   Phone:   
   eMail:

This form presumes that all members of your party will be attending on the same days. If this is not the case, please print the form multiple times, once for each schedule.

Mail your completed form and check (payable to "Big Scioty Barn Dance") to:

Dave Notman
5278 Timberline Rd.
Columbus, OH 43220-7306