The Break a Leg Experience Camp Registration

The Break a Leg Experience Camp Registration
Student Information
Student First Name *
Student Last Name *
Student Full Name
Student Phone Number
Please use a separate number from the parent/guardian if possible.
Student Email
Please use a separate email from the parent/guardian if possible.
Is student new to Break a Leg Theater Works?

Yes No
Student Date of Birth

Month Day Year
How did you hear about us?
Student Current Grade
Student's School
Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent/Guardian Information
Parent/Guardian First Name *
Parent/Guardian Last Name *
Full Name
Parent Email *
example@example.com
Parent Phone Number *
Please enter 10 digits only.

Emergency Contact
Same as Parent/Guardian information previously entered?
Emergency Contact Name
Emergency Contact Phone Number
Please enter 10 digits only.
Emergency Contact Email
example@example.com

Camp Selection

Please select the camp week(s) you are attending.
Camp Week Selection *

Week of July 25 (single week) - $425 Week of August 1 (single week) - $425 Both weeks - $700

Tuition Payment
Promo Code
Discount
Camp Total Cost
Installment Amount (4 installments)

Choose a payment option below. *

Pay In Full - The Break a Leg Experience Camp Tuition

USD one-time payment

4 Weekly Installments - The Break a Leg Experience Camp Tuition Split up the total into 4 weekly payments (repeats on this day of the week for 4 weeks).

USD for each week

4 Monthly Installments - The Break a Leg Experience Camp Tuition Split up the total into 4 month payments (repeats on this day of the month for 4 months).

USD for each month

Credit Card Information

After completing tuition payment, click Submit below to complete registration.
Should be Empty:

The Break a Leg Experience Camp Registration

Camp Selection

Tuition Payment

Credit Card Information