Adaptive Dance for Children with Down Syndrome

Student Information

Name*

First Last

Date of Birth*

Age*

Gender*

Academic School*

Grade*

Home Address*

Street Address Address Line 2 City State ZIP Code

I am registering my student for:*

Class for ages 5-10 (1-2 pm)
Class for ages 11-16 (2-3 pm)

Parent Involvement*

I acknowledge that my student must have a parent in the studio for the entirety of each class to encourage my student’s participation and manage behavior. The teacher will assess whether a student can participate in the class by themselves on a case by case basis throughout the Spring Session. I understand that without teacher’s permission, students will not be able to participate in class without parental accompaniment.

Parent Involvement*

I acknowledge that, although not initially required, the instructor may determine that a student must have a parent in the classroom in order to participate in class. This will be assessed on a case by case basis.

My student is a:*

New Student
Returning Student

Parent/Guardian Information

Relationship to Student*

Name*

First Last

Phone*

Email*

Emergency Contacts

Relationship to Student*

Name*

First Last

Phone*

Relationship to Student*

Name*

First Last

Phone*

Medical Information

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.

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/ID Number*

Releases and Authorizations

Tuition*

I understand that I am responsible for the entire session of tuition for classes for which I have registered for. Payment is required within five days of receiving the Paypal invoice to secure registration.

Class Structure Changes*

I understand that class time will total 45 minutes: 20 minutes of class, 5 minute break, 20 minutes of class.

Late Policy*

I understand that if my student is 10 minutes late or more to class, they are required to wait to join the class until the break, which occurs 20 minutes into the class period.

Medical Consent and Liability Waiver*

I am aware that dance and the nature of training and performing associated with Pennsylvania Ballet, may place unusual stress on the body 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 Pennsylvania Ballet and/or its representatives 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, 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 with 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, school property on which Pennsylvania Ballet classes take place, or other venue. I understand that Pennsylvania Ballet will not be responsible for the costs of any medical treatment deemed necessary by Pennsylvania Ballet's staff.

Authorization for Substituted Consent and Emergency Contact Information*

I hereby grant permission to the Pennsylvania Ballet or anyone designated by Pennsylvania Ballet, and to those persons listed above 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 Pennsylvania Ballet is given with the understanding that the organization and its designees, (1) 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 above designated 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 staff, and that such a determination shall be conclusive evidence of the reasonableness of the consent given. I agree to hold Pennsylvania Ballet, anyone designated by Pennsylvania Ballet and any employees, officers and directors 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.

Instructional Understanding*

I understand 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 concerns in this area should speak with the lead instructor.

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 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 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 my 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.

Adaptive Dance for Children with Down Syndrome

Student Information

Parent/Guardian Information

Emergency Contacts

Medical Information

Releases and Authorizations

You may also like:

Season & Tickets

Meet the Ballet

The School