Midland Theatre Ballet Application Form

Nutcracker 1-Day Ballet Course 2024

Monday 23rd December 2024 at Elmhurst Ballet School.
Student Information
Student Name*

First NameLast Name
Date of Birth*
DD/MM/YYYY
Age on 23rd December 2024*
Email Address (Parent/Guardian or 18+ Student)*
Mobile Number (Parent/Guardian or 18+ Student)*
Upload student headshot for ID purposes*

Cancelof
Dance School
Name of Dance School*
Name of Principle*
All students must have full permission and support from their Dance Teacher to take part in Midland Theatre Ballet's programmes. Please do not complete this form unless you have spoken to your Dance Teacher.*

I confirm that I have full permission and support from my Dance Teacher to apply for this programme.
Programme Information
Can your child leave the studios unaccompanied after the session?*

Yes, I give my permission.No, I do not give my permission.
MTB photographers may take photographs of me/my child during the intensive which may be posted online (e.g. social media).*

Yes, I give my permission.No, I do not give my permission.
Please tick the group you are suited to. For those aged 10 and 13 yrs old, please select which group you would feel most comfortable with:*

Age 7-10 yrsAge 10-13 yrsAge 13-21 yrs
Medical Information
Is there any medical information/allergies that we need to know about?*
Do you require any emergency medication (e.g. Epipen / Inhaler)?*
If an emergency occurs I/we give permission for a Midland Theatre Ballet representative to take the applicant to hospital*

Yes, I give my permission.
1st Emergency Contact Name*

First NameLast Name
1st Emergency Contact Phone Number*
2nd Emergency Contact Name*

First NameLast Name
2nd Emergency Contact Phone Number*
Privacy Policy
Please read our Privacy Policy in order to understand how your information is used and shared, and check below if you accept the policy.*

I have read, understood, and accepted the privacy policy for MTB.
Parent Signature / or Student 18+ Signature*

Clear
Booking Confirmation and Payment
T-shirt ordering deadline is 10th December 2024. After this, bookings will not be able to add a t-shirt due to the order deadline to ensure that t-shirts arrive in time for the course.

Please note: you can still book a place on the course as normal up until the day before the course starts (subject to place availability).