The 2017 Irem Shrine Circus will be held April 17th to April 22nd, 2017.

It is our hope that your group, limited to one (1) chaperone for each five (5) attendees, will attend as our guest. If more chaperones or parents are desired, there will be a charge of $4.00 per person. This FEE IS TO ACCOMPANY THE APPLICATION.

Please complete this form online, then print it. Fax the printed form to 570-714-0305 or mail it to the Irem Shrine Circus Office, 22 East Union Street, Kingston, PA 18704. Deadline for receipt is April 1st, 2017.

Handicapped will receive special consideration, however, we must limit wheelchairs to four (4) per show per group. Please list total attending and alternate performance dates. Your strict attention to seats requested and circus attendance will be greatly appreciated.

For more information, call the Irem Shrine Circus Office at (570) 714-0783.

Group Name Group Leader
Address Phone
Remarks      Preferred Seating:
     Main Floor Balcony
Special Instructions or Requests:
Monday 1:30 P.M. (4/17)   # of Children   # of Adults      
  # of Wheelchairs   # of Buses   # of Vans

Monday 7:00 P.M. (4/17)   # of Children   # of Adults      
  # of Wheelchairs   # of Buses   # of Vans

Tuesday 6:30 P.M. (4/18)   # of Children   # of Adults      
  # of Wheelchairs   # of Buses   # of Vans

Wednesday 10:00 A.M.* (4/19)   # of Children   # of Adults      
  # of Wheelchairs   # of Buses   # of Vans

Thursday 10:00 A.M.* (4/20)   # of Children   # of Adults      
  # of Wheelchairs   # of Buses   # of Vans

Friday 10:00 A.M.* (4/21)   # of Children   # of Adults      
  # of Wheelchairs   # of Buses   # of Vans

Print this Form