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Enrollment Information
PIN POINTS THEATRE'S
MIND, BODY, and SERVICE YOUTH PROGRAM
REGISTRATION FORM
Name______________________________________________________________________
Address____________________________________________________________________
City/State/Zip Code___________________________________________________________
Telephone Number_________________________Email_____________________________
Date of Birth (Optional)___________________Age (Optional)________________________
Emergency Contact_____________________________Telephone_____________________
Health Problems____________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Special Skills_________________________________________________________________
Interests____________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Signature__________________________________________Date____________________
For enrollment information, call: 202-582-0002
You may fax, email, or deliver this form.
Pin Points Theatre * 4353 Dubois Place, SE* Washington, DC 20019
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