2016 Registration form

Steen’s Mountain Ballet & Dance Studio                                             90 West Adams

A Division of   Healthy ‘N’ Fit   LLC                                                              Burns OR 97720

Kara Nelson Owner / Director                                                                541-589-3773

Students Name: ____________________________________   Date of Birth ___________________

Class(es)  Registering for   __________________  :   ___________________  : _________________

Parent / Guardian Names  and PHONE #_______________________________________________________

_______________________________________________________________________________________

Mailing Address: _________________________________________________________________________

_______________________________________________________________________________________

Parents E-mail Address: ______________________________________________

Emergency Contact and Phone: _________________________________________

____(initial)          I agree that I will not hold Steen’s Mountain ballet or Healthy ‘ n’ Fit LLC or Kara Nelson or any dance or fitness instructors  and / or parent volunteers  liable for any injuries sustained or illnesses contracted or personal materials lost, stolen or broken while child or myself is a student /client / volunteer / visitor   with Steen’s Mountain ballet or Healthy ‘ n’ Fit LLC.    

_____    I attest that the student is (will be)  prompt, dependable, attentive and cooperative.

                And that the student will wear clothing and shoes appropriate for dance.

_____    I agree that costumes and any extra performance props needed by the student will be at

an additional cost:  payable at the time such items are ordered.

Photo Release

__   I agree to allow Steens Mountain Ballet to use Dance related photos of my child for marketing proposes such as but not limited to Burns Times Heralds, Performance Announcements, Marketing Brochures, posts on Facebook or Blog site and other Displays.

__  I DO NOT want my child’s photo used for display or marketing.  I understand my child maybe asked to leave the dance area when such photos are taken of classes, events and performances.

               

Supervision Agreement  

I understand and Agree that Steens Mountain Ballet and its teachers and volunteers are not responsible for supervision or care any Students outside of their scheduled class time. Steens Mountain Ballet is not responsible for the supervision of sibling or visitors.   I understand that Steens Mountain Ballet does not supervise children being dropped off or picked up from the dance studio, performance locations or event locations.  

Parent / Guardian Signature: _________________________________   Date: _____________

Printed Signature: __________________________________________