Date: ____________________

Student's Name: _______________________________________________________________

Date of Birth: ___________________________Present Age: ____________________________

Parent/Guardian's ­Name: ________________________________________________________

Street Address: ________________________________________________________________

City: _______________________________________________ZIP: ______________________

Telephone:(H)___________________(W)______________________(C)___________________

E-Mail Address: ________________________________________________________________

How did you learn of County Ballet?  Newspaper   Flyer   Friend   Phonebook   Other _________

Liability Agreement: I agree that I will not hold a faculty member or an employee of County Ballet, liable for injuries sustained or for illnesses contracted by me/my child while a student/participant at County Ballet.  I agree to indemnify County Ballet and its faculty for all liabilities, costs, and judgments arising for acts of omissions of the undersigned, which result in injury or damage to any person or party.  I further agree that I will not hold County Ballet or any faculty member responsible for the loss or damage of personal property during participation.

TUITION MUST BE PAID IN FULL AT TIME OF REGISTRATION. 

Payment plans available for tuition over $300.

Checks, Cash and Credit Cards accepted.  There are no transfers, credits, or cash refunds for classes unless medical certification is presented.

Uniform Agreement: All students should have the required uniform within two weeks of starting classes and maintain a proper uniform throughout the semester.

I have read and understand the refund policy, uniform agreement and waive all claims of liability.  I am in receipt of County Ballet Class Policy Brochure.

Signature: ____________________________________________________________________

Printed Name: ____________________________________________ Date: _______________

•q     Dancer' s image may appear in ads? If you agree, please initial here: __________________

•q     DO NOT USE dancer's image on any advertising

List previous dance training or any medical problems the instructor should be aware of

Classes are subject to enrollment. Classes with less than 6 dancers are combined.

Textbook is required if registering for Ballet level A/ B or Pre Pointe Ballet.

$20 Registration Fee after September 6, 2008