Alternate Emergency Contact/relationship________________________________________ Phone _______________

Class(es) Registering for: Class #1 ___________________________________ Day__________ Time__________

                                      Class #2 ___________________________________ Day__________ Time__________

                                      Class #3 ___________________________________ Day __________ Time_________

                                      Class #4 ___________________________________ Day__________ Time__________

Additional Classes desired:____________________________________________________________________

Previous experience # years________Type of dance________________________________________________

Previous Studio (this helps with placement)________________________________________________________

Royal Academy of Dance examinations passed ____________________________________________________

Academic School currently attending ____________________________________________________________

PERMISSION STATEMENT

The above named person has my permission to attend Valerie Holgers' Academy de Ballet Classique (ABCBend). I confirm that this person is in good health and I know of no reason why he/ she should not participate in this form of artistic exercise. I am aware that dancing is a high impact form of exercise and that ABCBend will not be held responsible for any loss, damage or injury associated with participation in classes or events. I hereby give my permission to call the above named person and /or doctor for treatment in the event of injury or emergency. I further agree not to hold any ABCBend official or staff member responsible for any illness, accident or injury which might occur while in class or on ABCBend premises. I hereby verify that I fully understand and accept the above statement.

Parent/Guardian(or student if over age 18)_____________________________________ Date _______________ 

Permission to use my student's image in advertising ____Yes ____No (Please initial)

I have read and agree to tuition fees and terms of payment. All tuitions paid after the 5th of each month will be assessed a late fee, unless arranged in advance with the office. I understand there are no adjustments allowed for missed classes (makeups are gladly encouraged) I accept these fees and terms accordingly.

Parent (or Student if over age 18)___________________________________Date_________________________

Office Use only: Registered date_____________Amount Paid_______________