Summer programs 2023 Registration Form

Petit Allongé Bella NY

SUMMER PROGRAMS 2023 / 3-DAYS BALLET CHALLENGE
Student Information
Name*

First NameLast Name
Age*
Birth Date

MonthDayYear
Gender*

MaleFemale
School
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
How do you know us?*

FaceBookInstagramMixBFriendsFamilyOther
Did you take ballet class before?

YesNo
MUST READ BEFORE REGISTERING! ALL OF THESE POLICIES ARE ENFORCED. PLEASE DO NOT EMAIL ASKING OTHERWISE.We do not accept cancellation or refund. Refund will be accepted only for cancellation of lesson caused by the school. Unless early notification, we will not be able to cancel or refund after payment in any case.Payment can be made by Venmo and Zelle. * We do not accept payments at the studio.*

I have read and accept Policies.
Medical Release and Authorization: As legal guardian of the child listed on this form I hereby consent for him/her to participate in classes conducted by the Petit Allonge Bella NY Recognizing that any activity involving movement can create the possibility of injury. I will not hold any personnel, officers, agents or instructors liable for any injury that may occur before, during and after class or on the Petit Allonge Bella NY premises. I confirm that my child is in good health and I authorize simple first aid if necessary. I also understand that I am fully responsible for the total tuition session I registered for unless my child is unable to participate for medical reasons. In which case I will provide a signed medical notice from his/ her doctor.*

I have read and accept Medical Release and Authorization
Photo/Audio/Video/Social Media Release AuthorizationPhoto/Audio/Video/Social Media Release Authorization: I hereby irrevocably consent to and authorize the reproduction, publication and/any other use by The Petit Allonge Bella NY, his/her licensees and assigns, of the photographs/audio/video, in any medium and for any lawful purpose, including illustration, promotions, advertising, social media or web content, without any royalty or compensation to me. I assign to The Petit Allonge Bella NY any and all rights of ownership to the photographs/audio/video, the transparencies or digital files thereof, and agree that The Petit Allonge Bella NY has full right of lawful disposition in any manner. I waive any right to notice, inspection, or approval of any use of the photographs/audio/video which The Petit Allonge Bella NY , may make or authorize, and I release The Petit Allonge Bella NY , and his/her licenses and assigns, from any claim or liability arising from or in connection with The Petit Allonge Bella NY’s us of the photographs/audio/video or any alteration, processing or use thereof in composite form, whether intentional or otherwise.*

I have read and accept Photo/Audio/Social Media Release and Authorization.I have read and deny Photo/Audio/Social Media Release and Authorization.
COVID-19 Waiver I knowingly and willingly consent to have my child participate in programs with Petit Allonge Bella NY during the global COVID-19 pandemic. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show signs and symptoms and still be highly contagious. It is impossible to determine who has it and who does not with the current limits in virus testing.*

I have read and accept COVID-19 Waiver
Date*

MonthDayYear
Date
Signature*

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Petit Allongé Bella NY