2019-2020 School Registration Form

STUDENT INFORMATION

Fill out contact information only if different than Parent #1. Please note that student cell and email is required for students in the Professional Program.

Student's Name*

First Last

Date of Birth*

Age*

Gender*

Academic School*

Grade*

Home Address*

Street Address City State ZIP Code

Home Phone*

Student Cell Phone

Student Email

Returning Student
New Student

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 invoice tuition and receive communications from SPB.

Relationship to Student*

Name*

First Last

Address*

Street Address City State ZIP Code

Email*

Cell Phone*

Home Phone*

Work Phone*

Employer*

Occupation*

Parent #2

Phone numbers are required for Parent #2. Fill out remaining contact information for Parent #2 only if different than Parent #1.

Relationship to Student*

Name*

First Last

Address

Street Address City State ZIP

Email

Cell Phone*

Home Phone*

Work Phone*

Employer*

Occupation*

Additional Emergency Contact

Name*

First Last

Relationship to Student*

Cell Phone*

Home Phone*

Work Phone*

PROGRAM LEVEL

Select all that apply

Movement
Creative
Pre-Ballet Tuesday
Pre-Ballet Thursday

Pre Ballet* optional Saturday lesson (*In order to add the optional Saturday lesson, you must be enrolled in either the Tuesday or Thursday Pre-Ballet group above.)

Primary Monday/Wednesday
Primary Tuesday/Thursday
Fundamental A Monday/Wednesday
Fundamental A Tuesday/Thursday

Fundamental A *optional Saturday lesson (*In order to add the optional Saturday lesson, you must be enrolled in either the Monday/Wednesday or Tuesday/Thursday Fundamental A group above.)

TUITION INFORMATION

Payment Options:*

Payment in full (5% discount, must be paid by check ONLY)
Installment Payments (9 payments) - please see below

Registration Fee: $50.00 per child, $80.00 for family

First payment and registration fee will be invoiced to you by PayPal. This invoice must be paid within five days of receipt in order to secure the student's spot. There are 9 installments, the 1st is due with registration and the other 8 installments are due the first of the months: October through May. This is not a monthly tuition! You are committing to the year-round program which is divided into 9 installments for your convenience. If choosing this option, you must sign up for "Automatic Recurring Installment Payments". Forms will be sent to you after registration.

MEDICAL INFORMATION

All students must complete the Medical Information field. Students must submit a copy of their insurance and prescription cards by the first day of class. Copies can be submitted to the office in person, emailed to [email protected], or faxed to 215.625.4845.

Name of Insurance Carrier

Insurance Company Phone Number

Insurance Company Address

Street Address Address Line 2 City State ZIP Code

Name of Subscriber

Relation to Student

Type of Policy

Policy Number/ID Number

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

Yes
No

Please describe allergies:

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

Yes
No

Please describe illnesses or injuries:

STUDENT RELEASE FORM

Parents are responsible for the safety of their child. By making your permission selections and initialing below, and submitting this form, parents thereby release The School of Pennsylvania Ballet from all liability once their child has left the studio/theater(s).

Select permission for STUDIO*

Under age 12 - Not permitted to be released from the studio without a parent or guardian
Age 12+ - My child is not permitted to leave the studio on their own
Age 12+ - My child has permission to leave the studio on their own
I am a student over the age of 18 and therefore do not have to complete a Student Release Form

Select permission for THEATER(S)*

Under age 12 - Not permitted to be released from the theater(s) without a parent or guardian
Age 12+ - My child is not permitted to leave the theater(s) on their own
Age 12+ - My child has permission to leave the theater(s) on their own
I am a student over the age of 18 and therefore do not have to complete a Student Release Form

RELEASES AND AUTHORIZATIONS

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

Tuition*

The registration of my student is for the academic year which begins on August 26, 2019 and ends on June 3, 2020. Therefore, I understand that I am responsible for the entire year of tuition for classes for which I have registered for. Tuition is non-refundable/non-transferable. If you have chosen the installment payment option above, you must sign up for “Automatic Recurring Installment Payments”. Forms will be sent to you after registration.

Instructional Understanding*

It is understood that the nature of dance instruction involves kinetic corrections that may include physically touching a student as part of regular class work and rehearsals. Parents of students with any concerns in this area should speak with the School Director.

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 Director of The School of Pennsylvania Ballet or anyone designated by the 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 Director is given with the understanding that the Director, or the 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 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*

I understand that by initialing below, I am agreeing to accept the guidelines of The School of Pennsylvania Ballet as set forth above. SPB reserves the right to terminate a student's enrollment if they are unable to participate in accord with the school expectations of attendance or conduct. I understand that violation of any rule maybe grounds for instant dismissal from the school. I understand that should my actions warrant, I may be asked to leave The School. In such situation I understand no refund of tuition or fees will be forthcoming.

2019-2020 School Registration Form

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

Parent #1

Parent #2

Additional Emergency Contact

PROGRAM LEVEL

TUITION INFORMATION

Registration Fee: $50.00 per child, $80.00 for family

MEDICAL INFORMATION

STUDENT RELEASE FORM

RELEASES AND AUTHORIZATIONS

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