Second Stage'13 Registration Form
Thoroughly Modern Millie

Fee: $125 - First Family Member (includes a $25 per family registration fee)
$100 - Each Additional Sibling

Ages 18 & Up

Contact Annette at (856) 778-8357 or
email Annette@MoorestownTheaterCompany.org
if you have any questions about this form.

Medical & Media Releases

Medical Release: I release and hold harmless the Moorestown Theater Company, Inc. (MTC), and any of its officers, trustees, and/or staff, of any and all liability for any injuries or damages to me or my child, as a result of any function, rehearsal, or performance. Furthermore, all participants are physically fit (except as noted below) to participate in a theatrical production. I hereby authorize MTC to act for me in a medical emergency in the event that I cannot be immediately contacted. I also hereby assume responsibility for payment of any treatment.

Media Release: I will allow my name and photo and/or names and photos of my family to be used for promotional purposes, to be printed in the production’s program, and/or to be posted on the MTC website and advertising materials.

I acknowledge reading each of the above items, I understand each of them, and I by clicking on the box below, I agree to abide by each of them.

I agree to the terms in the MTC Releases listed above. *

Yes

Participant's Information

First Name *

Last Name *

Check the second item if you previously registered someone for Second Stage '13, otherwise check the first item.

Participation Fee *

2S '13: First Family Member ($125)

2S '13: Additional Family Member ($100)

Birthday:

(mm) *

(dd) *

(yyyy) *

Age (Opening Night) *

T-Shirt Size *

Gender *

Cell Phone (10 digits only)

Email Address

Allergies / Medical Conditions

Do you want to add another participant? *

Yes

No