Summer Student Registration Form

Name:_________________________________________________
Address:_______________________________________________
______________________________________________________
Phone:_________________________________________________
Email:_________________________________________________

$_____________, which amount I authorize The New Hazlett Theater to charge to my credit card listed below.
____Visa ____Mastercard ____American Express

Cardholder’s Name: ______________________________________________________
Credit Card #: ______________________________________________________
Expiration Date: ______________________________________________________
Signature of Cardholder: ______________________________________________________
Today’s Date: __________________