Parent’s Name____________________________________________________________

Address_________________________________________________________________

City_________________________ State__________________Zip__________________

Phone____________________________ Cell Phone_____________________________

Email___________________________________________________________________

Please check if you have made any address/phone changes from the previous year.

STUDENT INFORMATION

Non-Refundable Registration Fee: 35.00 per student to be returned with application

*Please include requested class names, days and times below.

Name___________________________ Birthdate________________ Age____________

Classes Requested ________________________________________________________

_______________________________________________________________________

Name___________________________ Birthdate________________ Age____________

Classes Requested ________________________________________________________

_______________________________________________________________________

Name___________________________ Birthdate________________ Age____________

Classes Requested ________________________________________________________

_______________________________________________________________________

PARENT RELEASE

I understand that Ballet Western Reserve will provide adequate supervision for classes and activities in which my child participates. Ballet Western Reserve will make every reasonable effort to insure the safety of all participants. I am also aware that Ballet Western Reserve will not assume responsibilities for any and all accidents, injuries, or loss of personal effects. I acknowledge I have been given the right to enroll in an accident and medical expense plan; however, I am electing not to enroll. I release Ballet Western Reserve from liability from any injury which may arise and waive any claim which hereafter may arise.

Parent Signature______________________________________________ Date_____________________

PARENT INFORMATION

Father’s Name_________________________Phone (if different)___________________

Address (if different)_______________________________________________________

Occupation_______________Employer____________________Phone______________

Mother’s Name_________________________Phone (if different)__________________

Address (if different)_______________________________________________________

Occupation______________Employer_____________________Phone______________

PAYMENT/EMERGENCY INFORMATION

Person responsible for payment______________________________________________

Phone _____________________ Address______________________________________

Emergency Name_________________________________________________________

Relationship_____________________________ Phone___________________________

BALLET WESTERN RESERVE

2007-2008 STUDENT MEDICAL INFORMATION

Student’s Name___________________________________________________________

Physician’s Name_________________________________________________________

Physician’s Phone_________________________________________________________

Dentist’s Name___________________________________________________________

Dentist’s Phone___________________________________________________________

Are there any medical conditions that Ballet Western Reserve should be aware of?

(Please list any allergies or medications)

_______________________________________________________________________

The undersigned Parent or Guardian of _______________________,

(Ballet Western Reserve student)

acknowledges that Ballet Western Reserve is a School which does not participate in dance competitions. Accordingly, no student of Ballet Western Reserve may participate in a dance competition identifying an affiliation, in any way, with Ballet Western Reserve or its faculty.

If the above-identified student desires to engage in competition, he or she is doing so independent of Ballet Western Reserve and its faculty. The above-identified student may not utilize choreography or classroom combinations produced by Ballet Western Reserve or its faculty in any way for competition.

__________________________________
(Signature of Parent or Guardian)

Return all forms to: Ballet Western Reserve, P.O. Box 1684, Youngstown, Ohio 44501-1684