,

Name: ____________________________________________________________
Address: ___________________________________________________________
City: ____________________________ State: ______________ Zip:__________
Birth Date: _______________ Age as of 6/2/14: ________ SS#: _______________
Home Phone: __________________ Alternate Phone:_____________________
e-mail: _____________________________________________________________
Age Group:

Seniors (13-21)
Group Act (no more than 5 persons)

Sprouts (2-12)
Solo Act

If group act, list other persons in the group.

Name

Home Town

Birth Date

Age
as of 6/2/14

Briefly describe your act:______________________________________________

Song title (if applicable) : _______________________________
Will you need use of a piano?

yes

Will you have an accompanist? yes

no
no

If yes, Name of accompanists: _________________________

Do you require a microphone? yes

no

How Many: ______

Hold Harmless Agreement: I agree to indemnify, hold harmless and defend Denmark Heritage Days,
Its individual members and directors against any and all claims arising out of or resulting from my
participation in the Denmark Heritage Days "Bill Riley Talent Search". In addition, I hereby certify
that I have read and agree to follow the rules of the contest and to respect the judges' rulings.
Participant Signature: ________________________________________ Date: ________________
Participant Parent/ Guardian Signature: __________________________________________

Questions please contact Jenni Hoenig (319) 470-7121 or jennihoenig@me.com

Send Entry Form to: Denmark Heritage Days, c/o Jenni Hoenig,
PO Box 226, Denmark, IA 52624