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Roseville School of Dance <br />Im <br />olf " I IIaHH P �� �: � 1"I'l7f . . .. .. .. .. .. it" <br />"Ier i(,, .... .. . . . <br />r ')fjj] <br />is iI�,, r <br />"I"i :wly" cz; I'll <br />d, (1, <br />0 :�'�[-Yyoj,t ix dance bagl an( I hea(."'] <br />s, <br />a',[", [4,l, 0 t"'I 111 "'ll, v z z a, a m e Is, raft, <br />'117 '11, <br />-tl ��,H , 3 II ... . .. .. . .. .... 3 1 N 1, g,, I "'a c e "I,,), O,t ],nce C ac 1" e a f/1' a 1, IIIH <br />C r a zi'I,'Ir 117,1 (1 1 ( . . ...... . <br />i, r <br />"I rig, a rij, d, (""'Ylt u se 1',),A'1N( I IN' ".� VIII VIII VIII <br />"31''1"), xf%ir e v, <br />E 'i�, sl3a ces Y uu <br />11 1),11"1 E,0 'r", f"11 <br />Is at',, th e d o <br />t a Ilk" ...... . g <br />1", -:11 -,11 L IS tl`�,]`)(E��` Ili <br />YL I 'III "") E`11 t-o e a(, <br />it <br />9 . .. .. .. .. .. <br />3 , <br />P 1, a el call, 6 11, 92A 4, 77 <br />( In, a "��n, C <br />"1 111) h I "I, C, o �f 1, <br />x: (�:::111 �1 E�I'd �Iz', ''11, e <br />p a rt C J 1) a In, tz;; , 1-i I dL. <br />1111 <br />n� ]n, r I <br />il Z1111. z"'. i"�1-1�1 d,,�ill, xlj% , I'l, b e 017-1 (led <br />d < (-)iiA[7jll7 1`11 d i i Is e <br />. . <br />311" 1 1 r kji, l <br />10 a n, 't", <br />v e Is a <br />t <br />11 <br />J� Irj�, C T1 I <br />lass tl,, o Ct o <br />Ym i c a r��, e g i r st", <br />, C l- ( I I , yal or b 'r J III o iLl, C1a r <: Is <br />3 <br />cl t", a ct, a r k Is a ]n, d R, e c e at,, jill, o r��, ol i, c e <br />W, I " ..� m 1�1111 ,re " <br />0 A, 1, 1 (-"l (:::1, 11h ()01, <br />h 11,�rijl ls'-�, ev <br />..... . ..... . <br />e 1, ( 11 e <br />w� 1, 1, 1 J1, a I "I I 'N'Ji Gi� j,'t" <br />W1 Ilk 11"', C " IS I 1 9 ,�l 61111 1 <br />1, A I,J 2 <br />W11''I"'N" IS a ti I I," C <br />M a CI 2 <br />.. .. .. .. .. .. .. .. fll <br />,1,) 3 01,11,111,118 0 0 <br />W1 I <br />Y <br />C, e nt,ll a r (."'o rr'i lil, 1 11,11, t"ly j"Y"I"D <br />ra] <br />III C ....... . .. I d 1 2,1 <br />K 91 <br />M N !E 15 'l, 13 <br />Z 0 Is N) i 11 <br />P11111111 111"I'v <br />III :,I�l 2 1 ,,,1 42 4, <br />C $1, 6 <br />------------------------------------------------------------------------------------------------------------------------------------------------------------ ,,, '.�11 a. ,,,, „.�,,,,,, � �i, i �1 �i' ��, ii e ��� NATNAI W <br />1"?,oseville 1"I'ar"lli's and .,..ill k „ �,,,�µ V� V,. V V I,,, 'W <br />T <br />17 2 17 <br />I�� 2 171 `1 11' "D�: <br />FV 11 E�1'1 11 <br />�hr� 113f,-�"r'SIAT� I'll ,),)i �friafl� at��� (��)s i �1 e IV! 1�,' IS 5113 -,- 1 79 <br />11, ly ''I (��) r� �,, <br />Name: <br />Address: <br />Email: <br />Kid's Night Out - Roseville School of Dance 5th Annual Program # 2901.424 $16-00 <br />Home Phone: <br />City: <br />Cell: <br />State: Zip: <br />Birth date: <br />Does the participant have any special needs, or allergies our staff should be aware of? Yes No <br />If yes, please explain: <br />Form of Payment: Check Cash Visa Master Card American Express <br />Credit Card Number: <br />NI <br />Cardholder's name: <br />Parks & RecreaWn Deportn"wenj <br />Cardholder's Signature: <br />Exp: <br />