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Registration Information:
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Register before 10/4/2010 |
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List Names of People |
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Clown: |
x $85 |
=______ |
..._____________________ |
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Kid Clown (age 10-16) |
x $65 |
=______ |
..._____________________ |
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Register After 10/4/2010 |
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Clown |
x $90 |
=______ |
..._____________________ |
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Kid Clown (age 10-16) |
x $70 |
=______ |
..._____________________ |
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Register at the Door |
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Clown |
x $95 |
=______ |
..._____________________ |
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Kid Clown (age 10-16) |
x $70 |
=______ |
..._____________________ |
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The Extras |
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Advanced Gospel Magic |
x $40 |
=______ |
_____________________ |
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Successful Sales & Marketing Nov. 3 & 4 |
x $75 |
=______ |
._____________________ |
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| ___ | Fun & Funny Magic Nov 5 |
x $40 |
=______ | _____________________ | ||
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Face Painting
Nov. 4 |
x $60 | =______ | _____________________ | ||
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Clown Ministry Nov. 5 |
x $40 | =______ | _____________________ | ||
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Little Big Top (Ages 8-16) |
x $25 | =______ | _____________________ | ||
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Balloon Mania Nov. 5 |
x $40 |
=______ |
._____________________ |
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x $30 |
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_____________________ |
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x $30 |
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S___M___L___XL___ |
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TOTAL |
$________ |
**one Dinner/Show ticket is included with each KCD registration!
Name: _____________________________ Phone: _____________
Address: _____________________________________
City/State/ Zip: ________________________________
Total enclosed: ______________ e-mail: _____________________
Credit Card # Expiration Date
Name and Address on the Card Billing: (Cards processed through Mirthworks, Inc)
Name Street Address Address (cont.) City State/Province Zip/Postal Code Country
Total Amount Charged on your credit card
Signature for your credit card _______________________________________
OR send funds via Paypal to KissellTalks@cs.com
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After filling in
form, print & mail form and
payment to: KCD, |
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or fax to: secure fax line # 757-489-1587 |
Questions? Call Steve @ 757-423-3867 or E-mail to KissellTalks@cs.com
Cancellation Policy: If a written cancellation is received by Oct 3, your registration will be refunded less a $15 fee. After this date, you may send a substitute.
KCD Hotel
Information
Holiday Inn Lakeview
www.Holiday-Inn.com/ClarksvilleKY 812-283-4411 $69.95 for single/double rooms.
Please register by October 3rd and mention you are with KCD for discount.
Business Center, Gift Shop, Beauty Salon, Indoor Pool, Fitness Center and RV parking.
www.KentuckyClownDerby.com return to Kentucky Clown Derby main page
© Copyright 2001-2010 by Kurt Flickner (Steve Kissell's web-servant) last up-date 07/29/2010