Child #1:

Address:

City:

Zip:

Register On Line

DOB:

Age:

Child #2:

Age:

DOB:

Home Phone #:

Mobile Phone #:

E-Mail Address:

Emergency Contact:

Parent/Guardian:

Work/Cell #:

Phone #:

T-Shirt Size #1:

Costume Size #1:

Insurance Carrier:

Policy #:

Subscriber:

Child's Physician:

Address/City/Zip:

Physician's Ph #:

Hospital Preference:

Allergies/Medical conditions requiring medication:

11-12 Payment Option Selected:

11-12 Voluntary Fundraising (Season):

11-12 Mandatory Recital Fundraising (Season):

2011-12 Payments/Fundraising

Medical Information

Additional Registration Info

Please complete

ALL SECTIONS

when registering

-All information submitted will be populated on to a registration form; signatures of parent and child are required in designated areas for registration completion.

-Please review all payment options before making selection. (ONLY one time payment/lump sum allowed ONLY for Comp. Audition Workshop).

PayPal Payment Options are available on "SPECIALS PAGE"

-Please review fundraising options before making selections.

-Registration Form in its entirety is available for print on CLASSES page (in the Calendar & Forms section).

Sex:

T-Shirt Size #2:

Costume Size #2:

2011-12 Season Apparel and Costumes