Exit ESR - Fall 2023 Registration Form Sign your child up for Exchange Street Records Rock Program at Auburn Public Theater! Please fill out this form to the best of your abilities. If you have any questions, you can contact Mo Allyn via email at molly@auburnpublictheater.org or text them at (315) 237 - 2539. Question Title * 1. Child/Student Information Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Phone Number Question Title * 2. What is your child's date of birth? Question Title * 3. What is your child's main instrument? Question Title * 4. Parent/Guardian Information Name Company Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 5. Emergency Contact - Parent/Guardian #2 Information Name Company Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 6. How did you learn about Exchange Street Records fall program? Question Title * 7. Please list any medical conditions your child may have that you would like our staff to be aware of. Question Title * 8. Please confirm the details of the program your child will be attending below. Exchange Street Records Rock Band Camp ($250) - Monday September 18 - Monday December 11 5:30PM-7:00PM; Student Showcase TBA Question Title * 9. Please indicate if you would like to be contacted about scholarship options. Yes No Question Title * 10. METHOD OF PAYMENT: Cash Check (made payable to Auburn Public Theater) PayPal @auburnpublictheater Credit Card Question Title * 11. Photo Release: I give Auburn Public Theater permission to use any photos taken of my child for promotional materials. Yes No Question Title * 12. Signature PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Signature Submit
