Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
Address: *
City: * State: * Zip: *
Emergency Contact Info*
Students entered below will be added to your family's account
Last Name*
First Name*
Teen Email Address *
Phone Number*
Parent Name*
Parent Email*
Parent Phone Number (Home)
Parent Phone Number (Cell)*
Emergency contact name and phone number.*
Are you currently homeschooled? *
If you are not currently homeschooled, who are you a guest of. (If you are the homeschooler type NA)*
Vegetarian / Vegan*
Please list any food allergies.*
Will you be 18 years of age the day of the event? *
I give permission for my child to sign themselves out at the end of prom. I understand once my child is signed out the LA Homeschool Prom is no longer responsible for my child. If 18 years click yes.*
Who is your favorite recording artist?
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number: *  
Name as it appears on card: *
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*