SUMMER 2019- Middle School Registration Form
Welcome to Broken Leg Productions, we are so excited for the summer ahead and that you will be joining us. Once your registration is complete you will receive a confirmation email with receipt of payment within 48 hours. Feel free to contact us at firstname.lastname@example.org with any questions you may have.
Parent 1 Name
Parent 2 Name
Additional Email (Optional)
Please only e-mail me information pertaining to this program
Please e-mail me regarding all BLP youth programming
Please add me to the BLP general mailing list
Address Line 2
Town, Zipcode, State
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)
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.
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
I am registering for:
Snoopy: The Musical
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.
-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)
Name On Card
Expiration Date (mm/yy)
CVV (3 or 4 Digit code found on the back of your card)
Billing Zip Code