Backyard Ballroom - En Pointe School of Ballet LLC.

Registration & Medical Release Form

Backyard Ballroom LC will be En Pointe School of Ballet LLC.
Student Name*

First NameLast Name
Are you signing up as a leader, a follower, or as a couple?*

LeaderFollowerLead/Follow Couple
Partner Name*

First NameLast Name
Which consecutive course months are you signing up for?*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(Under 18) Student Name
First & Last Name
(Under 18) Student Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact*
Provide name and phone number please
Are there any medical conditions we should be aware of? (If so, explain please)*
How did you hear about us?*
Who referred you?
Please tell us where
What are your goals regarding dancing?
Consent/Release Waiver

Dance activities may carry a risk of injury to the student or participating individual. Some of these risks include: sprains, dislocations, bruises, broken bones etc. We, the staff members of Backyard Ballroom, LLC, will do our best to prevent injuries and accidents to participating students/individuals. It is with this understanding that I enroll my child/myself into a program at Backyard Ballroom, LLC (Hosted at En Pointe Ballet Studio). If the need arises for medical treatment, I do hereby grant authority to the Backyard Ballroom, LLC staff to transport or obtain transportation to the nearest hospital or treatment center. I further agree that, due to my understanding of the inherent risks involved, the owners and instructors who work with my child(ren)/myself shall not be held liable for any damages arising from personal injuries sustained within the En Pointe Ballet Studio facility or at any event associated with Backyard Ballroom, LLC or En Pointe Ballet Studio. I hereby fully release and discharge the Backyard Ballroom, LLC and En Pointe Ballet Studio owners and instructors from any and all damages, demands, rights of actions, claims, present, and future. Tuition is due on the first of each 12-week session. If a class is cancelled due to inclement weather or other unforeseeable event, a makeup lesson will be offered.
Please Read & Sign Below

I, the undersigned student, parent or guardian, have read, fully understand and agree to the above policies of Backyard Ballroom, LLC and En Pointe Ballet Studio. I hereby give my permission to Backyard Ballroom, LLC to use photographs and/or videos of the dancer listed above as deemed appropriate for the promotion of Backyard Ballroom, LLC.
Student (If under 18 Parent/Guardian Signature)*

Clear

Pre-Pay Tuition Option (Guarantees Your Spot In Course.)

Single-Student 12-Week "Dance Essentials" Group Class Tuition Product Image

Single-Student 12-Week "Dance Essentials" Group Class TuitionSingle-Student (Leader or Follower) 12-Week "Dance Essentials" Group Tuition. Includes a single 12 consecutive week course covering a Ballroom, Latin, & Swing social dance style.

$144.00 Quantity

Couple-Student 12-Week "Dance Essentials" Group Tuition Product Image

Couple-Student 12-Week "Dance Essentials" Group TuitionLeader & Follower Couple-Student 12-Week "Dance Essentials" Group Class Tuition. Includes two 12 consecutive week course tuitions for a Leader & Follower couple covering a Ballroom, Latin, & Swing social dance style.

$240.00 Quantity

Total

$0.00

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Date*

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Date
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Registration & Medical Release Form

Credit Card