OFSRDC Insurance Update Form

OFSRDC

Oregon Federation of Square and Round Dance Clubs

Insurance Information Update Form

Use this form to add new dancers to your insurance coverage. Coverage is effective immediately, through the end of the calendar year. Please remember to send your check made out to OFSRDC for $5.25 per new dancer to:

Vicki Pounds
PO Box 61
Canby, OR    97013

If you would like to receive a copy of the report, enter your email address below. Otherwise, the email address is optional.

Club name:
Your council:
Your name:
Your email:

Dancer name(s):
Address:
City, State, Zip:
Phone:

Dancer name(s):
Address:
City, State, Zip:
Phone:

Dancer name(s):
Address:
City, State, Zip:
Phone:

Dancer name(s):
Address:
City, State, Zip:
Phone:

Dancer name(s):
Address:
City, State, Zip:
Phone:

Click here when done: