Student Registration Form

Basic Information
Full Name*

First NameMiddle NameLast Name
Age on date of registration*
Email*
Phone Number*
Birth Date*

MonthDayYear
Which level would you like to register for?*

Pre Junior after schoolJunior after schoolPre Professional after schoolWeekly Program
Present Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact

First NameLast Name
Relationship
ex. Father, Mother, etc.
Address Of Person To Contact In Case Of Emergency

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Of Person To Contact In Case Of Emergency
Please enter a valid phone number.
Email Of Person To Contact In Case Of Emergency
example@example.com

Training
Current Ballet School*
Current Ballet Teacher*
Height and Weight*
Headshot*

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Photo in 1st Arabesque*

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Please verify that you are human*
RISK AND LIABILITY AGREEMENT: I understand that Singur Ballet students requires a high intense physical activity, usually performed on a hard or lightly-padded surface without protective footwear. It is also understood that dance instruction involves kinetic corrections that may include physically touching and manipulating the body of the student as part of regular class work. I understand that participants engage in a broad range of quick movements, bending, twisting, running, leaping and lifting, which place extreme demands on the body, I also understand that the Singur Ballet is not staffed to monitor and supervise the activities of its students at all times, and we do not contemplate constant supervision. I also understand that there are inherent risks of serious personal injury involved in all of the above activities. I voluntarily assume and accept such risks of personal injury and illnesses arising from my/our children's attendance and participation in such activities. I hereby give permission for Singur Ballet to take and/or use photos and/or videos of me for promotional, educational purposes.*
Please write I agree
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