(Date & Time)

at The Farmville Baptist Church, 132 N. Main St., Farmville, Virginia .

(Location & Address)

Contestant’s Name _____________________________________________________________

(First, Middle, Last)

Parent or Guardian _____________________________________________________________

Address ______________________________________________________________________

_______________________________________ ______________ _____________________

(City (State) (Zip)

Phone ________________________________ Age _____________ Grade ______________

School ___________________________________ Email _____________________________

Type of Instrument _______________________ Type of Voice ________________________

Composition __________________________________________________________________

Composer ____________________________________________________________________

Accompanist ________________________________________ Phone ____________________

Recommended by Music Teacher _________________________________________________

(Name)

Phone _______________________________________________________________________

______________________________________________________ _____________________

(Signature of Contestant) (Date Signed)

Please mail registration form to:

Farmville Lions Club

c/o BR Breen

1555 Hardy Drive

Farmville, VA 23901

Revised 10-01-07