Register for Dance Classes Thank you for choosing BalletRox! A place where all youth are given "a chance to dance". "*" indicates required fields Contact InformationParent or Guardian Name* First Last Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Email* Emergency Contact (other than primary contact)Name* First Last Phone*Student InformationName* First Last Birth Date* MM slash DD slash YYYY Ethnicity* Race* PreferencesPreferred Location*Spontaneous Celebrations (Jamaica Plain)Vine Street Community Center (Roxbury)Where did you hear about our classes?*Spontaneous Celebrations (Jamaica Plain)Vine Street Community Center (Roxbury)Referral Name* (write N/A if none)Preferred Class* Spontaneous Celebration - Mondays, 4:00 pm - 5:00 pm Beginning Ballet (ages 6-9) Spontaneous celebrations - Mondays, 5:00 pm - 6:00 pm Ballet (ages 10+) Spontaneous celebrations - Mondays, 6:00 pm - 7:00 pm Intro to Ballet for Teens (ages 13+) Spontaneous Celebrations - Wednesdays, 4:00 pm - 4:30 pm Creative Movement (ages 2.5 - 3) Spontaneous Celebrations - Wednesdays, 4:30 pm - 5:30 pm Combo Ballet/Tap (ages 4 -6) Spontaneous Celebrations - Wednesdays, 5:30 pm - 6:30 pm Jazz/Musical Theatre (ages 6 - 9) Spontaneous Celebrations - Wednesdays, 4:00 pm - 5:00 pm Tap II (ages 10+) Spontaneous Celebrations - Wednesdays, 5:00 pm - 6:00 pm Tap I (ages 6 - 9) Spontaneous Celebrations - Wednesdays, 6:00 pm - 7:00 pm Jazz/Hip-Hop (ages 10+) VSCC - Saturdays, 9:30 – 10:00 am Creative Movement (ages 2.5-3) VSCC - Saturdays, 10:00 am – 11:00 am Combo Ballet/Tap (ages 4-6) VSCC - Saturdays, 11:00 am - 12:00 pm Pre-Ballet (ages 4 - 6) VCSS - Saturdays, 12:00 pm - 1:00 pm Hip-Hop or African (ages 6 - 9) Spontaneous Celebrations - Saturdays, 9:30 am - 10:00 am Creative Movement (ages 2.5 - 3) Spontaneous Celebrations - Saturdays, 10:00 am – 11:00 am Combo Ballet/Tap (ages 4-6) Spontaneous Celebrations - Saturdays, 11:00 am - 12:00 pm Pre-Ballet (ages 4 - 6) Spontaneous Celebrations - Saturdays, 11:00 am - 12:00 pm Afro-fusion (ages 10+) Spontaneous Celebrations - Saturdays, 12:00 pm - 1:00 pm Teen Ballet (ages 13+) Waiver of Liability* I agreeI, ____________________________________________, (parent/guardian’s name) hereby give my child, _________________________________________ , (child’s name) permission to dance at the BalletRox. I waive the right to any legal action against BalletRox for any injury sustained on studio property or at any BalletRox event. I understand that I am enrolling my dancer in a program of physical activity and have agreed that my student is in good physical condition and does not suffer from any disability that would prevent or limit participation in this dance program.Photo Release Form & Agreements* I agreeI give full rights to the BalletRox, Inc. and its staff to use photos and video images of me or my child to use for promotional purposes of the BalletRox, Inc. only. Photos and video will be used in brochures, website, advertisements, and other promotional material created by the organization. Photos may appear with or without names in press releases and other print advertising. I have read, understand, and agree to the above stated waiver of liability, medical and photo releases. I have also read and understand the “BalletRox, Inc. Policies and Information”. I understand I will be held responsible for all tuition, costume payments, and late fees as listed.Medical Release Form* I agreeI, ________________________________(parent/guardian’s name) hereby give permission for any and all medical attention to be administered to my child, _______________________________ (child’s name), in the event of an accident, injury, sickness, etc., under the direction of the physician listed below or at any necessary emergency facility, until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment. This release is effective for the period of one year from the date given below. Insurance Company* Add RemovePolicy Number* Add RemoveChild Physician* Add RemoveAddress* Add RemovePhone* Add RemoveKnown Allergies* Add RemoveThis site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
