Registration for: St. Louis ShagStarting Wednesday, December 14, 2016
First Name:
Last Name:
Street Address:
City:
State:
Zip:
Telephone:
Email:
Role:Leader Follower
Please enclose $12 in the form of a check, payable to Groove Juice Swing.
Mail to: Groove Juice Swing 315 E. Henrietta Rd. Rochester, NY 14620