High School Summer Institute Application

Simpson College

Summer Theatre Institute for

High School Students

Name_____________________________________________

Address___________________________________________

City_______________________________________________

State___________________________Zip_________________

Home phone_________________________________________

Cell phone___________________________________________

Email_______________________________________________

Male___________ Female__________ Birth date___________

Grade you will enter in the fall of 2008_____________________

School name__________________________________________

Parent/guardian_______________________________________

Parent/guardian work phone_____________________________

Relationship to student__________________________________

I hereby waive and release Simpson College and the camp director
and teachers from liability and cost from injury.

Signature______________________________________________

Payment:

Amount $_____________________ Date_____________________

_________Check/money order (payable to Simpson College)

_________Mastercard (2% processing fee will be charged)

Card #__________________________________________________

Exp. date________________________________________________

Signature________________________________________________

A nonrefundable deposit of $50 is required by June 6 to hold your
reservation. A confirmation letter will be sent on receipt of registration.

Pay in full by: June 6 $430.00
July 3 $470.00

No refunds after July 1, 2008

Mail registration and deposit payment to:
Ann Woldt
Theatre Simpson
701 North C Street
Indianola, Iowa 50125


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High School Summer Institute Application Simpson College Summer Theatre Institute for High School Students Name_____________________________________________ Address___________________________________________ City_______________________________________________ State___________________________Zip_________________ Home phone_________________________________________ Cell phone___________________________________________ Email_______________________________________________ Male___________ Female__________ Birth date___________ Grade you will enter in the fall of 2008_____________________ School name__________________________________________ Parent/guardian_______________________________________ Parent/guardian work phone_____________________________ Relationship to student__________________________________ I hereby waive and release Simpson College and the camp director and teachers from liability and cost from injury. Signature______________________________________________ Payment: Amount $_____________________ Date_____________________ _________Check/money order (payable to Simpson College) _________Mastercard (2% processing fee will be charged) Card #__________________________________________________ Exp. date________________________________________________ Signature________________________________________________ A nonrefundable deposit of $50 is required by June 6 to hold your reservation. A confirmation letter will be sent on receipt of registration. Pay in full by: June 6 $430.00 July 3 $470.00 No refunds after July 1, 2008 Mail registration and deposit payment to: Ann Woldt Theatre Simpson 701 North C Street Indianola, Iowa 50125
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