Contact Person:                                                               

Date:                                                      

Referred by:                                                                    

Time:                                    # of people (approx.):             

• Bellygram (1 song) 
• Short Show (2 songs)
• Show (3-4 songs)
• Show w/mini-lesson (3 songs + 15 min lesson - great for stagettes)
• Group Class (1 hr lesson - a fun "chick's night" idea!)

(for longer shows or further information, please contact us at the numbers above)

          ‘ Mirror Image (duet w/Lisa & Lara)   OR    ‘ Lisa    ‘ Lara   

Event: 

• Birthday
• Retirement
• Stag/Stagette/Shower
• Engagement Party
• Wedding
• Other:                                                                                  

Location:                                                                                      

         Facilities available for prior viewing:  ‘ No  ‘ Yes, anytime  ‘ Yes, w/appt

Special Requests/Comments:                                                                                                            

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(c) 2006 Lara Wadelius Kirkpatrick & Mirror Image Bellydancing Twins