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Class Information Reporting Form
Our insurance covers members of square and round dance classes without
additional charge, but only if their names and addresses are reported
to the insurance company. That's what this form is for.
If your class has more than 20 families, good for you! Just submit
the form several times.
Club name:
Choose one
Bachelor N Bachelorettes
Beachcombers
Blue Mountains Council
Braids & Braves
Buckeroo
Capitol Callers & Cuers Assoc
Cascade Callers & Cuers Assoc
Cast A Shadow
Central Oregon Council
Chaps & Petticoats
Charlie Brown Squares
Cherry City Cloggers
Circle-N-Square
Columbia River Dancers
Corvallis Squares
Country Cut-Ups
Crook County Mavericks
Dancing Friends
Eager Beavers
Emerald Empire Council
Happy Hoppers
Hayshakers
Heads to the Center
High Desert Dancers
Hoedowners
Independence Wagon Wheelers
Interstate Highlanders
Klamath Country Squares
Kountry Rhythm Rockin Outlaws
LaGrande Star Promenaders
Lebanon Square Circlers
Mid-Willamette Council
Misty Valley Cloggers
Mix N Mingle
Muddy Frogs
Oak Hills Squares
ORDTA
Portland Area Council
R Square D
Red Rock Squares
ReVuN'Q
River City Dancers
Rogue-Sis-Q Council
Rosetown Ramblers
Sagebrush Shufflers
Saints-N-Aints
Salem Swingin' Stars
Sets In Order
Silver City Squares
Single Trees
South Coast Council
Spin Cycle Squares
Star Promenaders
Sundown RidgeRiders
Sunset Promenaders
Sweet Home Squarenaders
Timber 8's
Timber Twirlers
Tri Squares
Tualatin Valley Council
Umpqua Area Council
Valley Squares
Wave Steppers
Whirl-A-Ways
Willamette Squares
Your council:
Choose one
Blue Mountains Council
Central Oregon Council
Eastern Oregon Council
Emerald Empire Council
Interstate Highlanders
Lincoln-Tillamook Council
Mid-Willamette Council
Portland Area Council
Rogue-Sis-Q Council
South Coast Council
Sunset Empire Council
Tualatin Valley Council
Umpqua Area Council
Your name:
Your phone:
Your email:
Class type:
Squares
Rounds
Class location:
Building address:
Day and time:
Start date:
End date:
Family #1 name(s):
Address:
City, State, Zip:
Phone:
Family #2 name(s):
Address:
City, State, Zip:
Phone:
Family #3 name(s):
Address:
City, State, Zip:
Phone:
Family #4 name(s):
Address:
City, State, Zip:
Phone:
Family #5 name(s):
Address:
City, State, Zip:
Phone:
Family #6 name(s):
Address:
City, State, Zip:
Phone:
Family #7 name(s):
Address:
City, State, Zip:
Phone:
Family #8 name(s):
Address:
City, State, Zip:
Phone:
Family #9 name(s):
Address:
City, State, Zip:
Phone:
Family #10 name(s):
Address:
City, State, Zip:
Phone:
Family #11 name(s):
Address:
City, State, Zip:
Phone:
Family #12 name(s):
Address:
City, State, Zip:
Phone:
Family #13 name(s):
Address:
City, State, Zip:
Phone:
Family #14 name(s):
Address:
City, State, Zip:
Phone:
Family #15 name(s):
Address:
City, State, Zip:
Phone:
Family #16 name(s):
Address:
City, State, Zip:
Phone:
Family #17 name(s):
Address:
City, State, Zip:
Phone:
Family #18 name(s):
Address:
City, State, Zip:
Phone:
Family #19 name(s):
Address:
City, State, Zip:
Phone:
Family #20 name(s):
Address:
City, State, Zip:
Phone:
Click here if you have more names to enter:
Click here when done: