Demonstration Information Request Form

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Name:           
Age of Audience: Young Children (age 6 and under) Children (age 7 - 12) Teens Adults All of the Above
Purpose of Demonstration? Entertainment Entertainment and Participation Teach Child Safety and Entertainment Draw More People to you Event
Are you a McCoy's Action Karate Student?    YES    NO

Other Comments:  

Mailing Address:           
Organization:
City:              ST:               ZIP:           
Email Address:           
Phone Number:           

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