Napa Ballroom Dancersapplication for Participation

Napa Ballroom DancersApplication for Participation

For June 2017 Through May 2018

Acceptance of this Application and fees (below) by the Board of Directors of Napa Ballroom Dancers Inc. (NBDI) entitles the named participants to attend the tenscheduled dance lessons, dance parties, and the New Year’s Dance Celebration hosted by the NBDI Board of Directors during the annual participation period at venues as scheduled by theNBDI Board and published on:

NapaBallroomDancers.com/Saturday-Night-Dances.

Name(s): ______

Address: ______

Phone: ______

E-Mail: ______

Please enclose a check for ___$95/single or ___$190/couple

Please make the check payable to: Napa Ballroom Dancers Inc.Fill in the form above, print and mail with your application fee(s) to: PO Box 3081, Napa, CA 94558. Save a copy for your recordsor, bring this form and a check to our next dance.

Please fill out the attached Demographic Information Sheet so that the Napa Ballroom Dancers can comply with the Napa Senior Center’s request to assist the City of Napa with receiving grant funding which can be used for facility improvements, enhanced programs, and services (and help to lower rental fees for the venue). You only need to provide this information once per year. This information is kept anonymously and used only as aggregate totals.

Demographic Information

Please provide the information below so that the Napa Ballroom Dancers can comply with the Napa Senior Center’s request to assist the City of Napa with receiving grant funding which can be used for facility improvements, enhanced programs, and services (and help to lower rental fees for the venue). You only need to provide this information once per year. This information is kept anonymously and used only as aggregate totals.

Group Name: Napa Ballroom Dancers Date: ______

First Participant

Napa County Resident? ☐Yes ☐No

Ethnicity origin or race:

☐Hispanic or Latino ☐White ☐ Black or African American ☐Asian or Pacific Islander

☐Native American ☐More than 1 ethnic group ☐Other ☐ Prefer not to answer

Age group: ☐ 18-49 ☐50-65 ☐ 66-75 ☐76+

Household: ☐1 ☐ 2 ☐ 3 ☐ More than 3

Annual Income:

☐ Less than $49,000 ☐$49,000-$56,000 ☐$56,000-$63,000 ☐ More than $63,000

Disabled? ☐Yes ☐ No

Second Participant

Napa County Resident? ☐Yes ☐No

Ethnicity origin or race:

☐Hispanic or Latino ☐White ☐ Black or African American ☐Asian or Pacific Islander

☐Native American ☐More than 1 ethnic group ☐Other ☐ Prefer not to answer

Age group: ☐ 18-49 ☐50-65 ☐ 66-75 ☐76+

Household: ☐1 ☐ 2 ☐ 3 ☐ More than 3

Annual Income:

☐ Less than $49,000 ☐$49,000-$56,000 ☐$56,000-$63,000 ☐ More than $63,000

Disabled? ☐Yes ☐ No

Please complete additional forms if more than two participants