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).

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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*

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Home Phone *

Work #

Cell #

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Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

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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 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 *

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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

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