The Newington Children's Theatre Company
743 North Mountain Road
Newington, CT 06111
Phone: (860) 666-NCTC (6282)
E-mail: nctc-on-tour@sbcglobal.net
Web: www.newingtonchildrenstheatre.org
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Broadway Kidz
Program Registration Form
Please complete and send with check for $100 per week, non-refundable deposit to address above.
Enrollment on first-come/first-enrolled basis. Paymen of depositt reserves seat in program.
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Please indicate week(s) desired:
____ Week #1: June 23-27 ($100 deposit) ____ Weeks 3&4: August 4-15
($200 deposit)
____ Week #2: July 28-August 1 ($100 deposit
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Deposits are non-refundable.
Balance of $125 per week is due by June 1. No refunds after June 1.
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Amount paid with this form $__________
Balance Due $__________
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Please list any medical concerns that should be brought to the instructor's attention:
(i.e., allergies, asthma, medications or physical difficulties)
_________________________________________________________________________
In the event of an emergency, please list name to contact other than the one listed above.
Name ______________________________ Relationship ______________ Phone # ____________
Emergency Address:
_____________________________________________________________________________________
Additional adults authorized to pick up participant:
Name(s): _______________________, _______________________, _______________________
Parent/Guardian Signature ________________________________________ Date _______________
Student's Name ____________________________ Male or Female Age____ Current Grade____
Parent's/Guardian's Name _________________________________
Street Address ____________________________ Town _______________ Zip _______
Phone: Home _______________ Work _______________ Cell: _______________
Parent's E-mail __________________________ Student's E-mail _________________________