Name ______________________________________________
(As it should appear in the Leavenworth Summer Theater program.
Address ____________________________________________
City
___________________ State ___________ Zip _________
Phone ________________
Payment Method:
____ Check enclosed for $ ______
____ Please charge $ _______ to my credit card:
Credit Card Information ____ VISA ____ Mastercard
Card Number _______________________ Expiration Date
Name as it appears on the card ___________________________
Signature __________________________
Please print and mail this form to:
Leavenworth Summer Theater
928 Pine Street
Leavenworth, WA 98826