Registration Form
* Required
Student #1 Name
Student #1 Birthdate
Student # 1 Grade
Student #1 Name of Class
Tuition Amount
Student # 2 Name
Student #2 Birthdate
Student #2 Grade
Student #2 Name of Class
Tuition Amount
Street Address
City
State
Zip Code
Home Phone Number
Cell Phone
Email Address
Check One:
A deposit of $25 for each program is will be paid by credit card at this time
Financial aid form has been submitted
I would like to pay the full balance by credit card at this time.
I am mailing a check for the $25 deposit
I am mailing a check for the full tuition
Credit Card Information
If you would like to pay by credit card, please complete the info below.
Name on Card
Type of Card
Mastercard
Visa
Billing Street Address
Billing City, State and Zip Code
Card Number
Expiration Date
3 Digit code on back of card
Electronic Signature
Clicking submit at the bottom of this form will serve as an electronic signature.
How did you hear about Oddfellows classes?
Friend
Flier
School
Mailing
Other:
Emergency Information
Must be completed.
Mother/Guardian Name
*
Father/Guardian Name
*
Street Address
*
City, State and Zip Code
*
Mother/Guardian Place of Employment
Father/Guardian Place of Employment
Home Phone
Cell Phone
Work Phone (for which parent?)
Emergency Contact
Please list two other persons in case the above cannot be reached:
Contact #1 name
Contact #1 Phone
Contact #2 Name
Contact #2 Phone
Does your child have any special needs or medical conditions we should know about?
Permissions
1) In the event that the parent/guardian named above or the physician named below on this registration form cannot be reached in an emergency situation, I hereby give permission for my child to be transported (by ambulance or in a privately owned vehicle) to Middlesex Hospital or any other nearby medical facility for medical attention. It is hereby understood and agreed that I shall assume full financial responsability for all costs regardless of what is covered by my insurance. 2) I agree to indemnify and hold harmless Oddfellows Playouse and its agents and employees and contracted artists from and injuries or damage caused by or resulting from my child's participation in the programs sponsored by Oddfellows. 3) I give permission for photographs and videos of my child to be taken during Oddfellows Playhouse programs and for those videos/photos to be used for promotional or other purposes. 4) I have read the above statements and agree to them. By clicking "submit" at the bottom of this form, I agree to all of the terms outlined above. This agreement will serve as my electronic signature.
Name of Person Completing this form
Date Form Submitted