Drama Kids of Loudoun County, VA Online Registration

Registration

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To register, please complete this form and select one of the payment options shown on the payment drop-down menu below. We will then process your registration form and charge your credit card for the payment option you select at which time your space in your selected class will be reserved. Credit card processing can take 5 business days or more. You will receive a confirmation email. If you have any questions please contact us at novadramakids@live.com or 703.726.1226!

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Referral Information

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Referral Name*

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier*

Promotional Code

Contact #1

Contact #1 First Name*

Last Name *

Type*

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Home Phone *

Work #

Cell #

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Confirm Email*

Portal Account Password

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Contact #2

Contact #2 First Name*

Last Name*

Type

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Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

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Employer

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Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Transportation*

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Allergies*

Medications (Leave blank if NONE)

Primary Doctor

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Transportation*

Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Enroll in Classes

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Student #3 (Show-Hide Details)

Student's First Name*

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Student Gender*

Birth Date*

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T-Shirt Size

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Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

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Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Transportation*

Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

Transportation*

Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

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Credit Card

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Exp Year *

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Address Line 1

Address Line 2

City

State

Zip*

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

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Student #2 (Show-Hide Details)

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Student #3 (Show-Hide Details)

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Student #4 (Show-Hide Details)

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