2024/25 Training Center Registration

2024/25 Training Center Registration

$50 non-refundable registration fee due by July 15th

Student Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Dancer Age*

Student Email, if desired

example@example.com

Are you a new or returning student*

NewReturning

Parent Email*

example@example.com

Preferred Parent Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Contact Information

Most correspondence will be done via E-mail, however please provide at least one phone number for necessary situations.

Parent/Guardian 1 Name*

First NameLast Name

Parent/Guardian 1 Phone Number*

Please enter a valid phone number.

Parent/Guardian 2 Name

First NameLast Name

Parent/Guardian 2 Phone Number

Please enter a valid phone number.

Parent/Guardian 2 Email

example@example.com

Medical Information Form

General Health of Student*

GoodFairPoor

Insurance Information

Insurance Company*

Policy or Group#*

Name of Primary Insured*

Relationship to Student*

Medical History/Information

Please answer the following regarding any conditions we should be made aware of in regards to your student's participation.

Does student have any known allergies (foods, medicines, insect stings, etc.)?*

YesNo

If yes, please list allergies and recommended treatment:

Does your child have asthma and/or use an inhaler?*

YesNo

If yes, what is the recommended treatment?

Does the student have any chronic or severe illnesses, injuries or recent surgeries?*

YesNo

Does the student require any special attention due to health problems?*

YesNo

If yes, to either of the above please explain:

Does the student use any hearing or vision aids?*

YesNo

If yes, please explain:

Does the student have any disabilities of which we should be aware?*

YesNo

If yes, please explain:

Has the student ever experienced seizures?*

YesNo

If yes, please provide any pertinent information:

Please list any other medical conditions we should know about:

Medications

Does student currently take any prescription or non-prescription medications, pills (other than vitamins)?*

YesNo

If yes, please list medications:

I give Florida Ballet permission to give the following to my student at their discretion, for acute pain not relieved by non-medical means.

Advil/IbuprofenTylenol/AcetaminophenNone of the above

In an emergency, when parental permission is not available, I hereby give my permission for a Florida Ballet staff member to consent to medical treatment for our child and/or ward. *

I am aware that dance and the nature of the training and performing associated with The Florida Ballet place unusual stress on the body and carry with them the risk of physical injury. On behalf of my child and myself, I assume the risk and agree that Florida Ballet at Jacksonville, Inc., the Training Center and the staff of this institution shall not be liable in any way for injuries sustained during attendance in classes, rehearsals, or related functions.

It is also understood that dance instruction involves kinetic corrections that may include physically touching a student as part of regular class work and rehearsals. Parents or students with any concerns should speak with their instructors before class.

I certify that I have read and fully understand this liability waiver and that all questions pertaining to this consent have been answered to my satisfaction.*

I, the undersigned, give permission to the Florida Ballet, and/or parties designated by The Florida Ballet to photograph/video me or the minor named below and use such photograph(s)/video(s) in all forms of media, for any and all promotional purposes including advertising, display, audiovisual, exhibition or editorial use.

I further consent to the use of my name or the minor’s name listed below in connection with the photograph(s)/video(s) if needed by The Florida Ballet and/or parties designated by The Florida Ballet.

I understand and agree that I or the minor listed below will not receive any payment for time, expenses or any royalty for the publication of the photograph(s)/video(s) or the use of my/minor’s name and I hereby release The Florida Ballet and/or any parties designated by The Florida Ballet from any such claims.

Parent Signature

Has your dancer been given a level placement*

YesNo

If yes, what level were they placed in?

If no, please first submit an Evaluation Request Form

How would you like to complete payment for the year?*

Annual - Total Amount due July 31st3 Semesters - Due August 15th, November 15th, March 15thMonthly - Due on the 15th of each month

Payment

Registration Fee

$50.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Consent to Medical Treatment

Liability Waiver

Photograph/Video Release Authorization