LEBC Logo Draft 2 - Sovereign Ballet- Erie PA Dance Studio

Student Name *

First

Last

Address *

City *

State *

Zip Code *

Student Age *

Student Cell Phone

Student Email

Ballet Experience/# of Years/Where: *

Parent/Guardian Name *

First

Last

Parent/Guardian that will receive studio information/primary contact.

Parent/Guardian Cell Phone *

Parent/Gaurdian Email *

Emergency Contact *

First

Last

Relationship to Student *

Emergency Contact Cell Phone *

Health Plan/Insurance Company

Pertinent Medical Information

Allergies, Medications, etc

How did you hear about us? *

RELEASE OF LIABILITY *

I have read and understand this statement

I acknowledge that dance instruction is strenuous physical activity involving the risk of physical injury and have taken all steps necessary to learn of any physical impairment(s) that would limit or affect my safe participation. I voluntarily assume all risks arising from my participation in dance instruction and hereby release and waive all claims against Sovereign Ballet or any instructor contracted by Sovereign Ballet to provide dance instruction and any and all of the other participants in class for any damages arising out of my instruction, demonstrations or performances. I further agree to hold harmless and indemnify Sovereign Ballet or any instructor contracted by Sovereign Ballet to provide dance instruction and any and all of the other participants in class from any loss, cost or expense, damage or injury arising from my participation in dance instruction, demonstrations or performances.

PHOTOGRAPH AND VIDEO RELEASE *

I have read and understand this statement

I hereby grant permission to Sovereign Ballet the rights of my image, likeness and sound of my voice as recorded on audio or videotape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

Why do you want to have ballet training? What do you hope to achieve with your dance training?

Answer to the best of your ability

Where do you see yourself in 1 year/5 years/10 years?

Answer to the best of your ability

How are you willing to commit to achieve those goals?

Answer to the best of your ability