EmailMe Form - SUMMER 2019- Middle School Registration Form

Student Name

First Last

Parent 1 Name

First Last

Parent 2 Name

First Last

Student Email

Parent Email

Additional Email (Optional)

Mailing lists

Address

Address Line 2

Town, Zipcode, State

Parent Phone

### - ### - ####

Student Phone

### - ### - ####

Student Age

Grade Entering in Fall '18 (must be entering 5th throuh 10th grade)

Adult Tee Shirt Size (xs-xxl)

How did you hear about BLP and our summer Programming?

Anything else we should know? Please use this space to let us know anything that would help to make this the best experience possible for your student (allergies, behavioral/ physical limitations, Epipens, etc)

Emergeny Contact

Name

Phone

### - ### - ####

Relationship to Student

Other people allowed to pick up/drop off child

If anyone other than parents or emergency contact will be picking up/dropping off student, please let us know here.

Name

Phone

### - ### - ####

Relationship to student

Unknown at this time, but will inform BLP if this changes.

No one else will be picking up/ dropping off my student

I give consent for my child to walk/ bike home

REGISTRATION

I am registering for: *

Snoopy: The Musical

Frozen JR.

Both Sessions

My student and I have read the cast contract document on the registration page and agree to adhere to the rules and regulations set forth. *

Yes

PAYMENT

-This is a secured form
-All registrations received before 4/15 will receive an automatic discount
-Please allow 48 hours for payment to process
-When processed you will receive a confirmation from Square (the company we use to process credit cards)

Discount Code (if available)

I would like to: *

Pay my full tuition now

Pay $100 of my tuition now with the rest due the day of auditions

I will be submitting a need based scholarship (No charges will be made until scholarship determinations)

Payment Method

Name On Card

Card Number

Expiration Date (mm/yy)

CVV (3 or 4 Digit code found on the back of your card)

Billing Zip Code