First Name:

Last Name:

Clown Name:

Lady's Name:

Temple:

ISCA Card No:

Address:

City:

State:

Zip:

Email Address

Phone Number:

Guest Name & Number:

I will compete in: I will compete in: White Face Auguste Tramp Happy Hobo Character Senior Paradeability 1 Man Skit 2 Man Skit Group Skit Single Balloon Multiple Balloon

Please let us know if this is your first competition: Yes or No

Registration Fees: Registration Fees: Before Jan 15th - Clown $160.00 Before Jan 15th - Lady $135.00 Before Jan 15th - Guest $135.00 After Jan 15th - Clown $185.00 After Jan 15th - Lady $160.00 After Jan 15th - Guest $160.00 Saturday Night Banquet (includes Black Camel Ceremony) - $20.00 per person Degree Work $10.00

Total Amount Due:

Emergency Contact Info: Name & Phone Number