REGISTRATION FORM

REGISTRATION

REGISTRATION DEADLINE: July 30th

Moonbeam Theatre Summer Theatre Camp
for ages 7 to 12

August 1 - 5, 2011
9 a.m. to 12 p.m.
Landmark Center, 3rd Floor
Viroqua, WI

Cost is $150/week. Days may be pro-rated.
Sign up a friend and receive a 10% discount (full week only).

Required *

Parent's Name *

Address *

Phone

Email *

Emergency Contact *

Emergency Contact Phone Number *

Child’s Name *

Date of Birth *

Grade *

Does your child play an instrument? If yes, what type?

What are your child’s hopes for camp?

Does your child have any allergies, physical conditions, or emotional challenges that we should be aware of? *