Roxy Theatre Group Online Registration

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Welcome to The Roxy Theatre Group Family! Pay September Tuition and get FREE Registration! ($65 Value) Offer only Valid Until August 30, 2024

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Referral Information

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Referral Name

Family Information

Family Last Name*

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Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Information (Other Than Contact #1 or #2) (Name, Relationship, Phone)*

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Parent 1 Occupation

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Contact #1

Contact #1 First Name*

Last Name *

Relationship*

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Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

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Contact #2

Contact #2 First Name

Last Name

Relationship

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Cell #

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Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

School*

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Disabilities (Leave blank if NONE)

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Immunization Notes

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Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Immunization Notes

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Student #3 (Show-Hide Details)

Student's First Name*

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Student Gender*

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Additional Info

Student Email

T-Shirt Size*

School*

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Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

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Medications (Leave blank if NONE)

Immunization Notes

Please click on the Search button below, then choose the class.

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Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size*

School*

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Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Immunization Notes

Please click on the Search button below, then choose the class.

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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*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Immunization Notes

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Enroll in Classes

Select Class *

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Credit Card

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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

Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

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