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Ticket Form
$25.00 per ticket
Name: __________________________________________
Phone Number: __________________________________
Email Address: __________________________________
Parent’s Phone Number: ___________________________
Gender? M / F
Are You a Member of HEARTS? Y / N
If not, who are you a guest of? _______________________________________________
What grade are you in this year? ______________________
What is your date-of-birth? __________________________
Payment Method by check only
Check #: __________ Payment Amount: _______
Please mail ticket form, permission form, check payable to Enid Trevithick and a selfaddressed stamped envelope (in order for a ticket to be mailed back to you) to:
Jill Brooks, 20982 Homecrest Ct., Ashburn, VA 20147
Questions? 703-858-2989 or [email protected]
Permission Form
It is our intent to provide an excellent event for the HEARTS home school community that will
allow them to experience an evening of celebration with their friends at the end of the school
year. This is a formal affair that is intended for you to get together as a group and enjoy each
other’s company as a group. Therefore, we strongly discourage couples from attending the prom
as “dates”. We have found that the most fun is had by all when everyone is willing to dance with
a lot of different partners. It is also important to treat the evening and other guests with the
respect they deserve by dressing in appropriate attire. With this in mind and in order to clearly
state our expectations for the evening, each participant must sign the following Dress Code and
Code of Conduct.
Dress Code:
 Men must wear dress slacks, dress shoes, button down shirts and a tie – suit jackets are
encouraged, but optional.
 Women, out of respect for others, low necklines revealing cleavage and dresses with
plunging backs are not permitted. Dresses must be 2 inches below your fingertips.
 You may contact Cindy Almario prior to the dance if you have questions about proper
attire or on how you may be able to modify a dress to meet dress code.
 We reserve the right to refuse entrance to anyone that is not dressed appropriately, so
please ensure that you and your guests are adhering to the dress code.
Code of Conduct:
 “Couples” are discouraged from attending with the intent of being exclusive (only
dancing with each other).
 Public Displays of affection will be grounds for immediate dismissal without refund.
 No smoking, drinking alcohol, or drugs are allowed on the premises before, during, or
after the prom.
 No outside food or beverages are allowed.
 Kindly respect the authority of the Chaperones.
 Once you leave the event, you may not return.
 Inappropriate or disrespectful conduct will be grounds for immediate dismissal.
I ___________________________________________________ have read and agree to abide by
the Dress Code and Code of Conduct for the Prom.
____________________________________________________ Student Signature
____________________________________________________ Parent Signature