TODAY'S DATE:  

E-Mail Address:

NAME OF PLAY:

Students First Name:   

Last Name:

Age:    Birth date: Month:   Day:   Year:    Sex: Male:  Female:

Name of School:    Grade:

Address:   City:   State:  

Zip Code:

Parent(s), Guardian(s) Name:

Home Phone Number:   Cell Phone Number:

How did you hear about our program?

Have you participated in any other Broadway Starz® shows?  Yes: No:

Which ones?  

Have you ever participated in theatre before?  Yes: No:

EMERGENCY CONTACT INFORMATION

Emergency Contact(s):

Name:  

Contact Number:

Name:  

Contact Number:

Are there any special medical considerations that we need to know about? (i.e.: allergies, diabetes, etc.):

PROGRAM ADDITIONS

Trophy: How do you want student's name to appear on trophy?

PAYMENT INFORMATION

How will you be paying for your registration of $235.00?

CASH:   CHECK:   CREDIT CARD :   PAYPAL:

We accept credit cards, bank transfers, debit cards, e-checks and more through Paypal

(If paying by Check, Credit Card or PayPal, please submit form first then come back to pay

There is an additional $10 fee to pay online with Check, Credit Card or Paypal

Cash or check can be mailed or brought to registration)

Please submit form.

When you arrive at the rehearsal hall we will have this registration form available for you to sign and date.

Thank You!