SOL CHILDREN THEATRE TROUPE

SUMMER CAMP 2010 REGISTRATION FORM

STUDENT’S NAME_____________________________________________________________

DATE OF BIRTH________________________                  AGE___________

HOME PHONE____________________  PARENT’S PRIMARY CELL PHONE______________

BUSINESS PHONE_________________ EMERGENCY NAME & CONTACT #______________

PARENT’S PRIMARY EMAIL ADDRESS____________________________________________

MAILING ADDRESS____________________________________________________________

PARENT’S (OR GUARDIAN’S) NAMES_____________________________________________

ANY MEDICAL CONCERNS?_____________________________________________________

I PREVIOUSLY TRAINED AT_____________________________________________________

I WAS REFERRED BY___________________________________________________________

CIRCLE THE SESSION(S) YOU ARE REGISTERING FOR:

I UNDERSTAND THAT PAYMENT MUST BE MADE PRIOR TO STUDENT PARTICIPATING IN CAMP … Signature of responsible party:

____________________________________________________ DATE:___________________

CIRCLE YOUR CHOICE :

SESSION 1

SESSION 2

BOTH SESSIONS

EARLY REGISTRATION REQUIRES PAYMENT IN FULL (unless other arrangements have been made through the theatre office)

AND IS NON-REFUNDABLE

Sol Children Theatre Troupe Inc.,

3333 N. Federal Highway, Boca Raton, FL 33431       

561-447-8829                       solchildtroupe@aol.com 

www.solchildren.org

IF PAYING BY CREDIT CARD:

CIRCLE CARD TYPE:

AM EX            DISCOVER     MASTER CARD             VISA

TOTAL DOLLAR AMOUNT: _________________________

CREDIT CARD NUMBER:___________________________

NAME as it appears on credit card:______________________

FULL ADDRESS street, city, zip code:

__________________________________________________

EXP. DATE:______               3 or 4 DIGIT SEC. CODE: ______

AUTHORIZING SIGNATURE:

__________________________________________________