Theatrix Productions, Inc. Online Registration

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Referral Information

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Family Information

Family Last Name*

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State*

Zip*

Primary Phone*

Contact #1

Contact #1 First Name*

Last Name *

Type*

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Student #1

Student's First Name*

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Student Gender*

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Additional Info

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T-Shirt Size*

School*

Grade Level*

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Primary Doctor

Please bring bottled water to class, rehearsal and/or performance. The only ingredient should be "WATER" only. Bottle should be labeled with your name. No other beverages, candy, gum and/or food permitted in the classroom, rehearsal hall or theatre. Keep DRAMA On-Stage! Thanks!

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T-Shirt Size*

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Medications (Leave blank if NONE)

Primary Doctor

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Medications (Leave blank if NONE)

Primary Doctor

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Medications (Leave blank if NONE)

Primary Doctor

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T-Shirt Size*

School*

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Disabilities (Leave blank if NONE)

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Medications (Leave blank if NONE)

Primary Doctor

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Referral Information

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Where do you live?

Contact #1

How Can We Contact You?

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Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

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