Lackawanna Historical Society - Registration Form for the
13th annual Grand Civil War Ball (Sat. April 22, 2017) and related events.


Name: ______________________________________________________________________
Address: ______________________________________________________________________
City, State, Zip: ______________________________________________________________________
Phone: ______________________________________________________________________
email: ______________________________________________________________________

Description

Quantity and Price

Amount

Dance Workshop
(single person registration)

____ number of single people at $10 each

_____

Dance Workshop
(registering as couple)

____ number of couples at $15 per couple

_____

Civil War Ball
(single person registration)

____ number of single people at $35 each

_____

Civil War Ball
(registering as couple)

____ number of couples at $60 per couple

_____

Ragtime Brunch

____ number of people at $27. each

_____

Total Amount Enclosed:

_____

Send this form along with a check made payable to:

Lackawanna Historical Society - Civil War Ball
232 Monroe Ave., Scranton, PA 18510

All proceeds benefit the Lackawanna Historical Society - Thank You for your support!