Summer Dance Experience Registration Summer Dance Experience ’24 Registration Thank you for choosing BalletRox. We welcome you to our dance & music family! "*" indicates required fields Contact InformationStudent Name* First Last Parent or Guardian Name First Last If student is younger than 18Home 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 InformationBirth Date* MM slash DD slash YYYY Ethnicity Race Disability Allergies PreferencesWhere did you hear about our camp?*GoogleCurrent StudentFacebookInstagramOtherPreferred Weeks* August 5-9, 9am-4pm August 12-16, 9am-4pm August 19-23, 9am-4pm August 26-30, 9am-4pm September 3-6, 9am – 4pm Select AllWaiver of Liability* I agreeI, ____________________________________________, (Your name / parent/guardian’s name if younger than 18) hereby give my child, _________________________________________ , (Your name / child’s name if younger than 18) 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 myself in a program of physical activity and have agreed that I am in a good physical condition and do not suffer from any disability that would prevent or limit participation in this dance program.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. 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 understand I will be held responsible for all tuition, costume payments as listed.Price* Price: $75.00 Credit Card* Cardholder Name Card Details This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
