Adult Name

Child Name(s)

Phone Number

Email Address

Address

City

State

Are you a VWC member?

Yes

Doors open at 5pm.

I understand.

Dinner will be served at 7pm.

I understand.

Ticket Fees

$20 (1 Adult & 1 Child)

$30 (1 Adult & 2 Children)

$40 (1 Adult & 3 Children)

$50 (1 Adult & 4 Children)

By typing my name below I verify that I understand doors will open at 5pm and dinner will be served at 7pm. I am authorizing Valley Wellness Center to charge my account on file the ticket fees checked above.

Total Ticket Fee

Daddy Daughter Dance

April 27

Total:

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Daddy Daughter Dance

April 27

Total:

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