Hayswood Theatre

115 South Capitol Avenue, Corydon, Indiana 47112          Tel:  812-738-4489

Youth Summer Theatre Workshop
Registration Form

Participant�s Name:_________________________________________________________________________________     

Participant�s Age: _____________   Participant�s Grade (as of Fall 2003) _______________

Parents or Legal Guardians Name: ________________________________________________________

Address: _____________________________________________________________________________

City: __________________________________   State:  _______   Zip: ____________________________

Contact Phone Number: ______________________   Secondary Phone Number: __________________

Insurance Name: _______________________________________________________________________

Policy Number: _________________________ Policy Holder�s Name: ___________________________

 How did you hear about the workshop? ____________________________________________________

Print off and mail/FAX completed form to:

Andrea Receveur
3816 Pine Creek Circle
New Albany, IN 47150
Fax: 812/542-0706