Fall 2010 Class Registration Form

Fall 2010 Class Registration Form
August 24 -October 26, 2010

---

CLASS* PLEASE SELECT WHICH CLASS YOU WOULD LIKE TO REGISTER FOR	Theatre Arts, August 24 -October 26, 2010 Musical Theatre, August 24 -October 26, 2010
NAME OF STUDENT ACTOR*
AGE*
PARENT/GUARDIAN NAME*
STREET ADDRESS*
CITY*
STATE*	Please select from the listAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto Rico Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Virgin Islands UtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
ZIP CODE*
E-MAIL ADDRESS*
HOME PHONE*
WORK PHONE*
CELL PHONE*
EMERGENCY CONTACT*
EMERGENCY CONTACT RELATION*
EMERGENCY CONTACT PHONE NUMBER*
DOES YOUR STUDENT ACTOR NEED ANY ADAPTIVE EQUIPMENT?*
DOES YOUR STUDENT ACTOR HAVE ANY ALLERGIES OR SPECIAL NEEDS WE SHOULD KNOW ABOUT?*
PAYMENT METHOD* A deposit of $50 is due to secure a place in class at the time of registration. Please provide your payment information (Visa or Mastercard number & expiration). If you are mailing a check, please denote in the box below the check number. Make checks payable to Dionysus Theatre and mail to 5300 N. Braeswood #226 Houston, Texas 77096 Balance of $75 is due the first day of classes.
Stop Spam* Please type the text you see in the box.

Return