Name (Last) (First) (MI) Sex M F
Address (Street) (City) (State) (Zip) Phone Email Birth Date Grade
Previous Training
Medical conditions we should be aware of

Parent Information

Mother/Guardian's Name (Last) (First) (MI)
Phone (Work) (Cell) Email
Employer Occupation
Father/Guargian's Name (Last) (First) (MI)
Phone (Work) (Cell) Email
Employer Occupation
Emergency Contact (Name) Phone

Liability disclaimer: I understand that dancing and dance classes constitute social/athletic/physical activities and that injuries may occur. I am willing and able to accept full responsibility for my child's safety and well-being.  I understand that good ballet training involves touching and adjustment of the student’s body by the instructor.  Acknowledging this, I hereby release and agree to hold harmless The Ballet School of Stamford and its employees from any and all claims and liabilities, which may arise out of my child's participation. 
Consent: I hereby irrevocably consent to and authorize the use and reproduction by The Ballet School of Stamford of any and all photographs, recordings, videotapes and/or other reproductions of likenesses of the child's person or characteristics for any purpose, whatsoever, without compensation to the student. All reproductions shall constitute the property of the school, solely and completely. Further, I assign and release all rights to said reproductions and authorize the school, or others authorized by them, to exhibit, broadcast, and/or distribute or otherwise further reproduce said reproductions in whole or in part over or in any medium whatsoever, including, without implied limitation, newsletters, radio, newspapers, closed circuit television, film, cable and television, with or without compensation in perpetuity. I/We also release, discharge and agree to hold harmless the producers or any persons, or entities acting under their permission or authority from any liability arising from the use of said reproductions. 
Policy Agreement: I have read, understand and agree to comply with all policies and procedures of The Ballet School of Stamford.  It is understood that the student is enrolled for the entire session; no deductions or refunds will be made for absence or withdrawal, voluntary or involuntary, unless for medical reasons.  

Parent/Guardian/Adult Student Signature
Date Signed