Registration Form

last name

*

first name

*

address

city

*

state

zip code

phone number

email

*

birth date

mm/dd/yyyy

Skill Level in Stage Combat

beginner

advanced

(Participants must be 18 years or older)

I'm interested in taking the Stage Combat Workshop for 3 hours
of college credit.

Yes No

- applies for Stage Combat only

Member of SAFD in good standing?

Yes No

T-Shirt Size

small

medium

large

x-large

Please list previous training

**A deposit of $100 is required with registration.
Your registration will not be processed until we receive your deposit.
Checks should be made payable to Eureka College.

Send deposit to:

Ms. Holly Rocke
Eureka College
300 East College Avenue
Eureka, IL 61530-1500

* required information