His Way Broadway Bye Bye Birdie: Youth Edition Student Registration
Student Name
*
First Name
Last Name
Age
*
Date of Birth
*
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Month
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Day
Year
Date
Student Name
First Name
Last Name
Age
Date of Birth
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Month
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Day
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Date
Student Name
First Name
Last Name
Age
Date of Birth
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Month
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Day
Year
Date
Student Name
First Name
Last Name
Age
Date of Birth
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Month
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Day
Year
Date
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Parent Contact Information
Mother's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Father's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Parent Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Additional Information
Adults allowed to pick up your children from class
Allergies or medical conditions of which HWB should be aware
Does your child carry an EpiPen?
*
Please Select
yes
no
Child's T-shirt Size *Please list the name of each child before shirt size. IE- Johnny: Youth Medium*
*
Deposit Payment Method
*
Cash
Check
PayPal (hiswaybroadway@gmail.com)
Venmo (studiofivesixteen)
Scholarship application pending
Submit
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