Windy City Line Dance Mania

October 6 – 9, 2016 ~ Registration Form ~ Please use one form per address!

Dancer #1 Name (Please Print)

/

City / State / Province /

Dancer #2 Name

/ ZipCode Country

E-mail Address #1

/ E-mail Address #2
Item & Description / Before May 1 / Before
Sep 1 / After 9/1 / QTY / SUB
TOTAL
WEEKEND PACKAGES
Gold Pass: Admission to ALL workshops, Evening Open Dancing, T-Shirt, Discounted Steps on Flash Drive or Book, Saturday DinnerReserved Seating Area for the Entertainment Show, and free video pass – Limited to 250 guests only.SELECT DINNER OPTION BELOW / $170 ea / NA / NA / $
Silver VIP Pass: Admission to ALL workshops, Evening Open Dancing,– Limited to 400 guests only Including above. SELECT DINNER OPTION BELOW / NA / $170ea / $180 ea / $
Group VIP Pass (8 or More People): - *BEST VALUE!* (Must send all registrations together in one envelope.) (See Appropriate “VIP Pass” for Description) SELECT DINNER OPTION BELOW / $165 ea / $165 ea / $175 ea / $
Saturday Night Dinner Option (Please Select w/ Gold/Silver Pass) Prices to the right are only if purchasing a dinner separately. Limit 200 People
Please Select from the following: (Includes Dinner Rolls, Salad, Dessert, Coffee, Tea and Iced Tea)
____ Chicken Mediteranian ____ Spinach Fettuccini ____ Roast Turkey
____ Gluten Free ____ Vegetable Lasagna (Vegatarian) ____ Chicken Marsala / $50 ea
(w/out Gold Pass) / $50 ea (w/out Silver Pass) / $55 ea(w/out Bronze Pass) / $
Check here is your meal must be ______Gluten Free ______Kosher (additional $10 charge applies – not included in GOLD / Silver Pass) / $10 (Kosher only) / $10 (Kosher only) / $10 (Kosher only) / $
4-Day Weekend Pass: Admission to ALL workshops, Evening Open Dancing And Saturday Evening Show. The evening show will be free to all purchasing a Saturday or Weekend Pass but without priority seating. / $125 ea / $125 ea / $135 ea / $
Group 4-Day Weekend Pass (Groups of 8 or More): (See 4-Day Weekend Pass description) / $120 ea / $120 ea / $130 ea / $
Weekend Spectator Only: For non-dancers - admission to watch friends and family on the dance floor (includes entertainment show but no dinner or buffet.)Name of Spectator:______/ $20 ea / $20 ea / $20 ea / $
DAILY PACKAGES
FRIDAY or SATURDAY(Circle One) Workshops & Open Dance Only / $80 ea / $80 ea / $90 ea / $
Step Description Booklet: ______Paper (Not Free!) &/or ______Flash Drive (Check format)
Please select whether you would like your step descriptions in a Paper Format or on flash drive grouped by instructor. Each dance flash drive will be in “.pdf” and can be read by your adobe acrobat program (a free program usually standard on all computers or can be downloaded).
* Paper is $15 w/ Gold VIP Pass or $20 w/out – Flash Drive is $5 w/ Gold VIP Pass or $10 w/out.
NO STEP BOOKS WILL BE MAILED! MUST BE PICKED UP AT EVENT / $15/20 Paper
$5/10 Flash Drive / $25 Paper
$10 Flash Drive / NA (Flash Drive can be purchased at the event) / ____ Paper
____ Flash / $
Event T-Shirt We highly recommend that you order before October 1st
Dancer #1 Size: S ____ M ____ L ___ XL ___ XXL ____ XXXL ____
Standard____ Ladies_____
Dancer #2 Size: S ____ M ____ L ___ XL ___ XXL ____ XXXL ____
Standard____ Ladies_____ / FREE w/Gold VIP Pass / $10 ea /
NA / $
CHOREOGRAPHY COMPETITION – NOTE: Requires purchase of a weekend pass.Please read rules located at prior to competition! You will be assigned a 30-minute time slot to demo and teach your dance. All step sheets must be submitted before 09/15/16 Only 12 slots will be assigned and only 1 entry allowed per person. / $25 / $25 / $25 / $
Grand Total: NO REFUNDS - TRANSFERS PERMITTED ,HOWEVER, ALL TRANSFERS WILL BE FOR BRONZE PASSES ONLY EVEN IF YOU PURCHASED A GOLD PASS. / $

I, the undersigned, for myself, my heirs, executors and administrators, hereby waive and fully release and agree to hold harmless the "WINDY CITY LINE DANCE MANIA" workshop weekend, its organizers, employees, and their agents harmless from any and all lawsuits, claims or demands of any and every kind and character arising from andin connection with this Event, whether as a spectator, staff member, or attendee. I understand the physical risks of social dancing and assume full responsibility for any injury or personal damages resulting from the " WINDY CITY LINE DANCE MANIA " workshop weekend. I hereby authorize the reproduction, sale, copyright, exhibition, broadcast and / or distribution of any event videotape and photographs of me during all the accompanying activities on Oct 6 – 9. 2016, without limitations. I certify that I am 18 years of older (application to Legal Guardian if under 18 years of age.)I understand and acknowledge that NO REFUNDS will be issuedunder any circumstances.
Dancer #1 Signature: ______Date: ______

Dancer #2 Signature: ______Date: ______

Credit Card: MC Visa Discover Billing ZipCode ______
#______Exp _____CVV ______
(3 or 4 digit security #)
Name of Cardholder ______
Signature______ / Form must be filled out and signed by person named.
Mail registration with payment to: Mark Cosenza
4250 N Marine Drive #2327
Chicago, IL 60613
Questions / Information,
Email Mark through his website at
All Checks must be made payable to Mark Cosenza