Children's Program Registration | Philadelphia Ballet

STUDENT INFORMATION

Name*

First Last

Date of Birth*

Age*

Gender*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

How did you hear about us?*

PARENT/GUARDIAN INFORMATION

Parent #1

Please note that Parent #1 will be the primary account name. This email address will be used to receive communications from SPB.

Relationship to Student*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Cell Phone*

Home Phone*

Work Phone*

Employer*

Occupation*

Parent #2

Cell and Work numbers are required for Parent #2. Fill out remaining contact information for Parent #2 only if different then Parent #1.

Relationship to Student*

Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Email

Cell Phone*

Home Phone*

Work Phone*

Employer

Occupation

ADDITIONAL EMERGENCY CONTACT

Name*

First Last

Relationship to Student*

Cell Phone*

Home Phone*

Work Phone*

TUITION INFORMATION

You will be sent an invoice by Pay Pal. This invoice must be paid within five days of receipt in order to secure the student’s spot. Tuition must be paid in full before your child starts classes.

MEDICAL INFORMATION

Does this student have any allergies of which we should be aware?*

Yes
No

If yes, please describe allergies:*

Does this student have any illnesses or injuries of which we should be aware?*

Yes
No

If yes, please describe illnesses or injuries:*

SELECT SESSION(S)/CLASS

SESSION 1: January 7 – February 13, 2020

Tuesdays

Creative Movement (Ages 3 - 4) 3:30 - 4:15 PM $120.00
Pre-Ballet (Ages 5 - 6) 4:15 - 5:15 PM $150.00

Thursdays

Dance with Me (Ages 2 - 3) 9:30 - 10:15 AM $120.00
Creative Movement (Ages 3 - 4) 10:30 - 11:15 AM $120.00

SESSION 2: February 18 – March 26, 2020

Tuesdays

Creative Movement (Ages 3 - 4) 3:30 - 4:15 PM $120.00
Pre-Ballet (Ages 5 - 6) 4:15 - 5:15 PM $150.00

Thursdays

Dance with Me (Ages 2 - 3) 9:30 - 10:15 AM $120.00
Creative Movement (Ages 3 - 4) 10:30 - 11:15 AM $120.00

SESSION 3: April 14 – May 21, 2020

Tuesdays

Creative Movement (Ages 3 - 4) 3:30 - 4:15 PM $120.00
Pre-Ballet (Ages 5 - 6) 4:15 - 5:15 PM $150.00

Thursdays

Dance with Me (Ages 2 - 3) 9:30 - 10:15 AM $120.00
Creative Movement (Ages 3 - 4) 10:30 - 11:15 AM $120.00

Classes are subject to cancelation.

RELEASES AND AUTHORIZATIONS

Please review the following releases and authorizations then indicate your agreement below.

Tuition*

Tuition is non-refundable/non-transferable.

Photo Consent*

I hereby consent to and authorize the use and reproduction by Pennsylvania Ballet of any and all photographs, recordings, videotapes and/or other reproductions of my child's likeness for any purpose, whatsoever, without compensation. All images shall constitute the property Of Pennsylvania Ballet, solely and completely. Further, I assign and release all rights to said images and authorize Pennsylvania Ballet, or others authorized by them, to exhibit, broadcast, and/or distribute or otherwise further reproduce said images in whole or in part over or in any medium whatsoever, including newsletters, radio, newspapers, film, cable and television. I agree that no material need be submitted to me or my child for approval, and that Pennsylvania Ballet has the right to edit, abridge, excerpt, or delete any and all of my child's likeness. I waive all rights and release Pennsylvania Ballet, its officers, boards, agents and employees, from any claim or cause of action, whether now known or unknown, for defamation, intentional or negligent infliction of emotional distress, invasion of right to privacy, publicity, personality, violation of any other property or moral rights, or any similar matter, based upon or relating to the use and exploitation of my child's likeness. I further waive and release any claim or cause of action related to any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur in capturing the likeness or in any subsequent processing or production.

Medical Consent and Liability Waiver*

I am aware that dance and the nature of the training and performing associated with The School of Pennsylvania Ballet place unusual stress on the body and carry with them the risk of physical injury. I understand that as parent/guardian I will be contacted if medical attention is required during class time. If I cannot be reached, I hereby authorize The School of Pennsylvania Ballet to arrange for treatment as necessary. I waive all rights and release Pennsylvania Ballet, its officers, boards, agents and employees, and shall indemnify, hold harmless and defend any such parties, except in cases of willful misconduct and gross negligence on their part, against any and all claims, actions, or suits brought for damages or alleged damages, and from all liability, loss and expense, including reasonable legal expenses, resulting from any injury to person or property or from loss of life sustained by my child while a student at The School of Pennsylvania Ballet or while fulfilling a role in any Pennsylvania Ballet production or event in which he/she has been invited to participate on or about Pennsylvania Ballet premises or other venue.

Authorization for Substituted Consent and Emergency Contact Information*

I hereby grant permission to the School Director of The School of Pennsylvania Ballet or anyone designated by the School Director, and to those persons listed below as emergency contacts to authorize emergency medical or surgical treatment, including, but not limited to, blood or blood product transfusions, diagnostic procedures, and the administration of anesthesia, for Student where medically appropriate in case of injury, accident, or illness: subject, however, to the following limitations (if none, so state): This authorization is given for the benefit of Student. The authorization given to the School Director is given with the understanding that the School Director, or the School Director's designee, (l) will act only in my absence, and (2) will act only until such time as I or my spouse or the Student's legal guardian or the persons designated below can be contacted. I understand that the medical appropriateness of such treatment shall be determined by the attending physician or by the medical facility's medical staff, and that such a determination shall be conclusive evidence of the reasonableness of the consent given. I agree to hold the School Director, anyone designated by the Director of The School of Pennsylvania Ballet and any employees, officers and directors of harmless from liability arising from any and all medical treatment, or complications arising there from, rendered as a result of consent given pursuant to this authorization.

Terms and Conditions*

Classes are subject to cancelation.
I understand that by initialing below, I am agreeing to accept the guidelines of The School of Pennsylvania Ballet as set forth above.

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

Parent #1

Parent #2

ADDITIONAL EMERGENCY CONTACT

TUITION INFORMATION

MEDICAL INFORMATION

SELECT SESSION(S)/CLASS

SESSION 1: January 7 – February 13, 2020

SESSION 2: February 18 – March 26, 2020

SESSION 3: April 14 – May 21, 2020

RELEASES AND AUTHORIZATIONS

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