Mosaic Youth Theatre of Detroit Online Registration

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Welcome to Mosaic's 2025 New Voices, Ambassadors, & Summer Camp Counselors Registration Page!

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Referral Information

How did you hear about us?*

Referral Name

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*

# of people in your household?*

Annual Household Income*

Do you receive food benefits?*

Do you receive cash benefits?*

Consider for scholarship? Y/N*

Contact #1

Parent/Guardian 1 First Name*

Last Name *

Relationship to Student*

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

Contact #2

Contact #2 First Name

Last Name

Relationship to Student

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email*

T-Shirt Size*

School*

Grade Level in Fall*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Student Race*

Student Gender*

For questions, please email Jimmie at jcomer@mosaicdetroit.org

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email*

T-Shirt Size*

School*

Grade Level in Fall*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Student Race*

Student Gender*

For questions, please email Jimmie at jcomer@mosaicdetroit.org

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email*

T-Shirt Size*

School*

Grade Level in Fall*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Student Race*

Student Gender*

For questions, please email Jimmie at jcomer@mosaicdetroit.org

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email*

T-Shirt Size*

School*

Grade Level in Fall*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Student Race*

Student Gender*

For questions, please email Jimmie at jcomer@mosaicdetroit.org

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email*

T-Shirt Size*

School*

Grade Level in Fall*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Student Race*

Student Gender*

For questions, please email Jimmie at jcomer@mosaicdetroit.org

Enroll in Classes

Select Class *

Add Another Student

Required Policies

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Questions or Concerns

Comments

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

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

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Required Policies

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