2005-2006 Registration & Medical Form
Pennsylvania Youth Theatre
School of Performing Arts
At The Banana Factory - 25 W. Third Street - Bethlehem PA 18015-1214
Phone: 610-332-1400 Fax: 610-332-1405 www.123pyt.org

Please register as soon as possible — classes fill early. Submit a separate form for each student.

* denotes a required field. 
Student's First Name *
 Last Name *
  
Age *
 Date of Birth
  
Grade *
 School
  
Address *
City *
 State *
 Zip *
Home phone *
 Alt. phone
 
Parent/Guardian *
 Employer
  
EMail

This is my year as a PYT Student.

PLEASE REGISTER MY STUDENT FOR THE FOLLOWING CLASS(ES):

Fee Schedule

Class 1
 Day
 Time
 Tuition $
Class 2
 Day
 Time
 Tuition $
Class 3
 Day
 Time
 Tuition $
Class 4
 Day
 Time
 Tuition $
   
TOTAL $  
   
MINUS DISCOUNTS $  
   
PLUS DEPOSITS $  
$50 per program      
   
TOTAL DUE $  

Please charge my MasterCard Visa in the amount of $ *
The $50 deposit per class per student is due with this registration.

Name on Card *

Account Number *

Exp. Date *
/

T-shirt Size:
Youth-S   Youth-M   Youth-L
Adult-S   Adult-M   Adult-L   Adult X-L

PYT Volunteer Corps opportunities for all parents of registered students:
Class Parent
Newsletter
Annual Gala/Auction
Program Advertising
Costume Crew
Community Representative

YES - I give permission for PYT to use any picture, electronic image and/or audio/video recording of my child for promotional purposes.

Would you like a family member or friend to receive information about PYT shows?
Student's First Name
Last Name
 
Address
Address
City
 State
 Zip
Relationship (grandparent, neighblor, etc.)

 

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All images Copyright © 2002-04 Pennsylvania Youth Theatre. No image may be reproduced without express written permission of Pennsylvania Youth Theatre.  * *  Photo Credit: All photos by Hub Willson

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