| (NOTE:
class scheduling is subject to change). |
Student
Name: |
Age:
Birth Date (mm/DD/yyyy):
|
Grade
in School: | |
Mailing
Address: |
City:
State:
Zip Code |
Mother: | Father: |
*Name
of Step Parent: |
*or
Legal Guardians |
| | Married Single
Divorced
Remarried
|
Is
there anything that SBA needs to know concerning your family (custody, living
arrangements, etc.).
|
Home
Phone
(w/ area code): | |
Mother's
Cell: | Father's
Cell: *Student's
Cell: |
Mother's
Email: | Father's
Email:*Student's
Email:*If
Applicable |
|
MEDICAL
/ EMERGENCY
|
Medical
or other special conditions that the dance instructor should be aware of:
|
|
In case of emergency,
call: , at (phone): .
Secondary
emergency contact (name): relationship
(neighbor, grandmother, etc.):
,
at (phone): .
|
|
REGISTRATION
AGREEMENT:
In consideration of the benefits derived from lessons and related
activities held under the direction of the School of Ballet Arts
at the home
of the Meiners' & at 585 N 1200 W. in Orem, I do hereby agree to indemnify
and hold harmless, release and
discharge its employees and owners, from any
and all claims for personal injuries of property damage occurring to or sustained
by our child while participating in aside dance activity.
|
Date (mm/dd/yyyy):
|
|
If
Applicable, referred by:
NOTE: You understand and agree that
by sending this electronic form via the internet by means of clicking the "Submit"
button
is the equivalent of your signature:
Yes
|