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: __________________________________________
