Hippodrome State Theatre
Registration Form

Your Name_____________________________ Child's Name_______________________

Grade (completed as of June 2005) ___________ Birthdate ___/___/___ Age_______ 

Hm Ph_______________Wk Ph_________________ Email_________________________

Address _____________________________________________________________

Emergency Contact Person Name:___________________________________

Number(s):______________________________ Relationship:_______________________

PAYMENT (Checks payable to Hippodrome State Theatre)
Amount Enclosed _________________  

____Check ____MasterCard / Visa  ____Discover ____American Express

Card Number________________________________________ Expiration Date_______
Security Code(it's the three digit number on the back of your card, after your account number, usually on the strip where you sign your name) :___________

Signature ___________________________________________

We must recieve all 4 REGISTRATION FORMS with your deposit and FINAL PAYMENT by the due date or your child WILL lose his/her spot . There will be NO REGISTRATION ON THE FIRST DAY OF CAMP.

PLEASE CHECK THE CAMP(S) THAT YOU WOULD LIKE TO ATTEND
Please note that the camps are broken down by ages.

Spring Break-A-Leg
April 5-9 (7-15years) ____
Summer Spectacular
Session I (June 6-July 1) Session II (July 11-August 5)
Summer Spec (7-12) _______ Summer Spec (7-12) ________
Class Act (13-17)__________ Class Act (13-17)__________

Student’s T-shirt size: CIRCLE ONE: Adult or Child AND CIRCLE ONE S M L XL

For families with more than one child in the program:
Would you like us to place both/all of your children in the same cast? ____yes _____no

People authorized to pick up your child (include authorized parents as well):