Performing Arts Enrollment

Please fill out all information below.

Please Note: Your credit card will be provisionally charged, but coverage cannot be put in force for 2 business days. If for some reason the insurance company denies to issue you a policy, you will be notified and the charges reversed.

*All Fields Required

Contact Name*
Name Of Performing Group*
Address*
City*
State*
Zip*
Phone Number*
Email Address*
Performance Information
Performance Name/Brief Description of Performance*
(insert Guide blurb here)
Performance Location*
(Name of Venue and Location Address)
Number of Shows/Dates of Shows*
What is the number anticipated for attendance?*
Your event needs to be less than 1500 individuals.
Policy Start Date for Event:*
Date Format: MM slash DD slash YYYY
Policy End Date for Event:*
Date Format: MM slash DD slash YYYY
Payment Information
Sub-Total
Price: $262.50
Processing Fee
Price: $10.00
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Optional Receipt
Would you like a receipt emailed to you?
- Yes
- No
Receipt will be mailed to
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Performing Arts Enrollment

Enrollment & Payment Form

Performance Information

Payment Information

Optional Receipt

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