Film - February & Spring Break Programming Registration Form

Sign your child up for our Music Video Program (February break) and Narrative Film Program (spring break) at Auburn Public Theater!

Please fill out this form to the best of your abilities. If you have any questions, you can contact Mo Allyn via email at molly@auburnpublictheater.org or text them at (315) 237 - 2539.

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* 1. Child/Student Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* 2. What is your child's date of birth?

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* 3. Parent/Guardian Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 4. Emergency Contact - Parent/Guardian #2 Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 5. Please list any medical conditions your child may have that you would like our staff to be aware of.

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* 6. Please confirm the details of the program your child will be attending below.

Music Video Program ($250) - Monday February 19 - Friday February 23 10:00AM-4:00PM; Student Showcase Friday February 23 at 6:00PM

Narrative Film Program ($250) - Monday April 22 - Friday April 26 10:00AM-4:00PM; Student Showcase Friday April 26 at 6:00PM

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* 7. Please indicate if you would like to be contacted about scholarship options.

Yes

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* 8. METHOD OF PAYMENT:

Cash

Check (made payable to Auburn Public Theater)

PayPal @auburnpublictheater

Credit Card

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* 9. How did you learn about our Film Education programs?

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* 10. Photo Release: I give Auburn Public Theater permission to use any photos taken of my child for promotional materials.

Yes

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* 11. Signature

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