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