The 2013 Irem Shrine Circus will be held April 1st to April 6th, 2013.

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 are desired, there will be a charge of $4.00 per person. This FEE IS TO ACCOMPANY THE APPLICATION.

Please complete this form, then print it. You may fax the completed 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 March 15th, 2013.

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.

Allan Rose (Guest Chairman). Phone (570) 654-3936.

Group Name Group Leader
Address Phone
Remarks      Preferred Seating:
     Main Floor Balcony
Special Instructions or Requests:
Monday Afternoon (4/1)   1:30 P.M. # of Children # of Adults    
# of Wheelchairs # of Buses # of Vans
Monday Evening (4/1)   7:00 P.M. # of Children # of Adults    
# of Wheelchairs # of Buses # of Vans
Tuesday Evening (4/2)   6:30 P.M. # of Children # of Adults    
# of Wheelchairs # of Buses # of Vans
Wednesday Morning* (4/3)   10:00 A.M. # of Children # of Adults    
# of Wheelchairs # of Buses # of Vans
Thursday Morning* (4/4)   10:00 A.M. # of Children # of Adults    
# of Wheelchairs # of Buses # of Vans
Friday Morning* (4/5)   10:00 A.M. # of Children # of Adults    
# of Wheelchairs # of Buses # of Vans
Saturday Matinee (4/6)   1:30 P.M. # of Children # of Adults    
# of Wheelchairs # of Buses # of Vans

Print this Form