CLASS REGISTRATION FORM
Please complete a separate form for each student
We accept Mastercard and VISA or personal checks.
.
Student Name__________________________
Parent or Guardian______________________
Mailing Address_______________________
______________________________
Street Address_______________________
______________________________
Email Address_______________________
Please enroll the student listed above in the following classes:
Class Title_________________________
Day ________________________ Fee $____________
Class Title_________________________
Day ________________________ Fee $____________
Class Title_________________________
Day ________________________ Fee $____________
Term: _____Fall _____Spring
10% discount for 2 or more classes $___________ TOTAL $__________
Payment in full is required for registration. Please enclose check or Mastercard
or VISA information:
Acct #_____________________________
Expiration Date__________________________
Please place in an envelope, and mail form and check to
HJT, Box 168, West Harwich, MA 02671.
Mother’s Name:_________________________
Home Phone: _____________________Work Phone:____________________
Father’s Name:_________________________
Home Phone: _____________________Work Phone:____________________
Guardian’s Name: ______________________________
Home Phone: _____________________Work Phone:____________________
In case of emergency, give names of persons who can be contacted during the
time your child is at the theater and are authorized to pick up your child if we cannot
reach a parent/guardian.
Name:_________________________
Relationship:_________________
Name:_________________________
Relationship:_________________
Please include a description of any chronic health concerns your child has,
including asthma, emotional, learning, etc. No medication will be administered
without parental consent. I understand that every effort will be made to contact
me in the event of an emergency requiring medical attention for my child. In
the event that I cannot be reached in an emergency, I hereby authorize Harwich
Junior Theatre to contact Harwich Rescue and to secure for my child the necessary
medical treatment. It is the responsibility of the parent/guardian to update this
form as necessary.
Parent / Guardian Signature_____________________
Date__________________