Omaha Theater Company/The Rose Theater Online Registration

Registration

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Please provide your information below and click submit when complete. Student costume and/or student fees will be applied after registration is submitted (if applicable, see brochure for more details). Annual registration fee is $15 per family (Registration fee is waived for members).

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier*

Rose Member - Type: Yes or No

Contact #1

Contact #1 First Name*

Last Name *

Relationship*

How Can We Contact You?

Home Phone *

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name

Last Name

Relationship

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size*

School*

Permission to Pick Up (Name & Relationship)*

Disabilities*

Special Needs (N/A if None)*

Allergies*

Medications*

Primary Doctor*

Authorized to Pick Up*

Describe Special Needs*

Sensory Needs (N/A if none)*

Communication Needs*

Disabilities*

Member discounts will be processed during review of registrations. Your payment will be processed after registrations have been reviewed and applicable discounts have been applied.

Enroll in Classes

Select Another Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size*

School*

Permission to Pick Up (Name & Relationship)*

Disabilities*

Special Needs (N/A if None)*

Allergies*

Medications*

Primary Doctor*

Authorized to Pick Up*

Describe Special Needs*

Sensory Needs (N/A if none)*

Communication Needs*

Disabilities*

Member discounts will be processed during review of registrations. Your payment will be processed after registrations have been reviewed and applicable discounts have been applied.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size*

School*

Permission to Pick Up (Name & Relationship)*

Disabilities*

Special Needs (N/A if None)*

Allergies*

Medications*

Primary Doctor*

Authorized to Pick Up*

Describe Special Needs*

Sensory Needs (N/A if none)*

Communication Needs*

Disabilities*

Member discounts will be processed during review of registrations. Your payment will be processed after registrations have been reviewed and applicable discounts have been applied.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size*

School*

Permission to Pick Up (Name & Relationship)*

Disabilities*

Special Needs (N/A if None)*

Allergies*

Medications*

Primary Doctor*

Authorized to Pick Up*

Describe Special Needs*

Sensory Needs (N/A if none)*

Communication Needs*

Disabilities*

Member discounts will be processed during review of registrations. Your payment will be processed after registrations have been reviewed and applicable discounts have been applied.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size*

School*

Permission to Pick Up (Name & Relationship)*

Disabilities*

Special Needs (N/A if None)*

Allergies*

Medications*

Primary Doctor*

Authorized to Pick Up*

Describe Special Needs*

Sensory Needs (N/A if none)*

Communication Needs*

Disabilities*

Member discounts will be processed during review of registrations. Your payment will be processed after registrations have been reviewed and applicable discounts have been applied.

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

Please fill out ONE of the following Payment Methods

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

State

Zip

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

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)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

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Student #5 (Show-Hide Details)

Additional Info

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Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

eCheck/Bank Draft

Required Policies

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