Old Registration Form

Registration Date *

Student Information

Student's Full Name *

Date of Birth *

Age *

Sex *

Male

Female

School *

Grade *

Medical Alerts

Ethnicity of Student *

Hispanic or Latino

Not Hispanic or Latino

Race of Student *

Please check all that apply

Registration Fee

New Student - $60.00

Returning Student - $40.00

Siblings - $25.00

Already Registered - Just paying tuition - $0.00

Tuition Fees - Tuition Assistance Available for those who qualify - Please complete Form and contact us for additional information / Payment Arrangements Available

Sibling Tuition Fees - Siblings 25% discount per class

Additional Class

Guitar - Tuesdays 4:30 - 5:30

Registration + Tuition Total

Parent / Guardian Information

Parent / Guardian Name *

Relationship to Student *

Street Address *

Apt. #

City *

State *

Zip Code *

Preferred Phone Number *

Alternate Phone Number *

Email Address *

Emergency Contact

Name *

Phone Number *

Relationship to Student *

Returning Students

Date of Last Registration

Release of Responsibility

In giving my consent, I further release YOUTH THEATRE INTERACTIONS, INC. (YTI) and its administrators, instructors, or any person acting on behalf of YTI of any responsibility for accident, not due to the negligence of said personnel.

Parent / Guardian Signature *

Clear

Date *