Wufoo

Student Name * First Last
Date of Birth * MM / DD / YYYY
*
Female Male
School
Grade in Fall 2012 *
2 3 4 5 6 7 8
Camp Session *
YOUTH MUSICAL • Pippi Longstocking • Grades 2-5 • July 2-21 MIDDLE SCHOOL MUSICAL • Through the Looking Glass • Grades 6-8 • July 23-August 11

(grade levels refer to the grade the student will be entering in Fall 2012, not their current grade)
Parent 1 Name * First Last
Parent 1 Email *
Parent 1 Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent 1 Home Phone Number * ### - ### - ####
Parent 1 Cell Phone Number ### - ### - ####
Parent 2 Name First Last
Parent 2 Email
Parent 2 Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent 2 Home Phone Number ### - ### - ####
Parent 2 Cell Phone Number ### - ### - ####
Payment Options
Pay $100 nonrefundable deposit now, by credit card Pay $100 nonrefundable deposit now, by check Pay full $1200 tuition now, by credit card ($100 nonrefundable deposit included within full tuition) Pay full $1200 tuition now, by check ($100 nonrefundable deposit included within full tuition) Pay $0 now and apply for need-based financial aid (limited availability)

$100 nonrefundable deposit due with registration.

If paying only the $100 nonrefundable deposit, the balance of $1100 is due April 20.

If paying by check, please Submit this form online and mail the check to 397 Miller Ave, Mill Valley, CA 94941 with the student's name and "Summer Camp" in the memo line.

Please note that there are no refunds after May 18.
I would like to make a donation to MTC's need-based Scholarship Fund.
$1200 (full tuition for a student who would not otherwise be able to attend) $600 (half tuition) $100 No donation at this time Other amount
Total Amount Now Due * $ Dollars . Cents
($1200 full tuition OR $100 nonrefundable deposit) plus (donation to Scholarship Fund)
Please charge my:
(leave blank if paying by check)
Visa Mastercard AmEx Discover Please call me so that I may give my credit card information over the phone.

Information about this web form's security measures: http://wufoo.com/security/
Credit Card number
Cardholder's Name
Expiration Date
CID
How did you hear about MTC's Summer Camp?
Word of mouth MTC's website Email from MTC I attended a play at MTC Ad in the Marin IJ Ad in Fast Forward I saw the brochure at my child's school A brochure was mailed to me My child participated in a previous MTC Summer Camp My child participated in another MTC program Other

Check all that apply.
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