Kinder Ballet Enrolment Form
Student Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Student age:
*
Medical Conditions/Allergies
*
Contact Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Day/s Attending
*
Please Select
Tuesdays
Thursdays
Both
Will you or the guardian be participating with your child?
*
Please Select
Yes
No
The first few classes (I would like to create independence)
Referred by Friend
Name of the student who referred you to Ballet Express to receive 10% discount off first term
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Parent/Guardians Information
Parent/ Guardian's Full Name
*
First Name
Middle Name
Last Name
*
Parent
Guardian
Relationship to student
*
Occupation
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Other information
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Emergency Contact Information
Full Name
*
First Name
Middle Name
Last Name
Relationship to student
*
Contact number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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Student Medical Information
Allergies
*
Medical Conditions
*
Additional Information
Does the student have any special needs or accommodations?
*
(if YES, please list)
Is there any additional information that we should know?
*
CONSENT AND RELEASE
I hereby authorize the staff of Ballet Express to act on my behalf in case of an emergency involving the student listed above. I understand that every effort will be made to contact me or the emergency contact listed above, but in the event that neither I nor the emergency contact can be reached, I give my consent for Ballet Express staff to seek emergency medical treatment for the student. I release Ballet Express and its staff from any liability in connection with the treatment of the student in case of an emergency.
Parent/Guardian Signature:
*
Date signed
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
This form will be kept on file by Ballet Express, and should be updated annually or as necessary to ensure that the emergency contact and medical information is current.
Submit
Submit
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