Eastern Shore Repertory Theatre Online Registration

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Referral Information

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Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

Health Insurance Carrier*

Contact #1

Contact #1 First Name*

Last Name *

Type*

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Home Phone *

Work #

Cell # *

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Email* (Emails are kept confidential)

Confirm Email*

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Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

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Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

School

Grade Level

Transportation

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes*

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

School

Grade Level

Transportation

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes*

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Student #3 (Show-Hide Details)

Student's First Name*

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Additional Info

Student Email

T-Shirt Size*

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Grade Level

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Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes*

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Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

School

Grade Level

Transportation

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes*

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Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

School

Grade Level

Transportation

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Immunization Notes*

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e-Payment Schedule*

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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*

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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?

Student #1

Additional Info

Enroll in Classes

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