The Mean Girls Dance Experience Registration Form
If you are registering for multiple people, please fill out this form separately for each person you wish to register.
Parent/Guardian Information
Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Full Name
Parent Email
*
Parent Phone Number
*
-
Area Code
Phone Number
Student Information
Is student new to Break a Leg Theater Works?
Yes
No
Student First Name
*
Student Last Name
*
Student Email (if applicable)
Student Age
*
Age in years
Student Grade
Student's School
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Payment
Would you like to make a donation to assist students with financial need?
Yes
No
Move the slider below to select a donation amount.
Cost
Total amount due: ${cost}.
Enter Promo Code
Discount
Total
*
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next
( X )
USD
Credit/Debit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: