Bill Riley Talent Show Registration
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Name *
First and Last name
Age *
Birthdate *
MM
/
DD
/
YYYY
Division  *
Type of Talent *
Type of Dance (if applicable)
Is a Keyboard Needed? (if applicable)
Clear selection
Song Name *
Street Address *
Town *
Zip Code *
Email Address *
Phone Number *
Submit
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This form was created inside of Jolin Media.