Debut Management, Inc.

You will need to submit this form for each session you wish to attend. A $50 registration fee is required for each session. Registration fees are non-refundable. Immediately upon submission of this form, you will be directed to our payment page at which time payment is expected.

Note: Name of person listed on this form must match name on credit card when payment is made.

Last Name:
First Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
E-mail:
Date of Birth:
Occupation:
	Please indicate which seminar you would like to attend: A $50 registration fee is required for each session. Registration fees are non- refundable.
Seminar:
Note:	If you are registering for the Tough Love Show you must complete the section below. Children must be accompanied by an adult. One adult is admitted with each child. You will be contacted once your registration is received. Please make certain your contact information is accurate.
Child's Name:
Age:
Grade:
Gender:
Race:
Presenting Issue:

By completing this registration and submiting this form you are the parent/guardian of this child and hereby give consent for this person to be taped with the understanding that his/her image or likeness may be used in for promotional or television purposes.