Centre Ballet Online Registration

Registration

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Welcome to Centre Ballet! We are so thrilled you are here! We have made registering your student as easy and convenient as possible! Let's get started!

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info
(Not Contact #1 or #2)*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone *

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name*

Last Name*

Type*

How can we contact you?

Home Phone *

Work #

Cell # *

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor*

Immunization Notes

Skill Notes

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor*

Immunization Notes

Skill Notes

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor*

Immunization Notes

Skill Notes

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor*

Immunization Notes

Skill Notes

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor*

Immunization Notes

Skill Notes

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Assumption of Risk

I, the undersigned, do not hold Centre Ballet, LLC, or any of its employees, staff or guest faculty responsible for any accidents that may happen by nature of the physical activity engaged in on these premises.

I understand that the art of dance and nature of dance instruction may sometimes require a teacher to touch my child/me. I also understand that this will happen in a caring, gentle and appropriate manner.

____ I hereby grant the staff of Centre Ballet, LLC, permission to administer first aid help, and /or call the student's physician, and/or call 911 in case of a medical emergency while attending classes or rehearsals at Centre Ballet or rehearsal or performances off site. Centre Ballet will attempt to first notify parents or guardians in the case of an emergency (see Consent Form).

____ I have read and accept the tuition policy (found in registration packet). I understand that I am responsible for the full tuition for which the above student is registered.

____ I authorize and consent Centre Ballet, LLC, the use and reproduction of any and all photographs taken of my students for samples, displays, promotions, advertisements and other legitimate purposes without compensation.

____ I authorize Centre Ballet to include my name, address, email, phone number, student name and class level in a student/parent directory.

I've read the above and agree.

Release of Liability

I/we hereby release and hold harmless the Ballet, its agents and employees from any and all damages, whenever or wherever suffered, arising out of or in connection with any act or failure to act, including any negligent act or failure to act, by the Ballet, its agents and employees, in the good faith exercise of its authority under this Consent. I/We further agree to indemnify and hold the Ballet, its agents and employees harmless from and against any and all costs or expenses incurred on behalf of the Child.I, the undersigned, do not hold Centre Ballet, LLC, or any of its employees, staff or guest faculty responsible for any accidents that may happen by nature of the physical activity engaged in on these premises.

I've read the above and agree.

Medical Emergencies

I/We, the parent(s) or legal guardian(s) of the above named minor child ('Child') who is legally under my/our care, custody and control, voluntarily consent and delegate my/our legal authority to consent to health care services on behalf of the Child to the Centre Ballet, LLC, its agents and employees (the 'Ballet"). Notwithstanding the foregoing, nothing in this Consent shall be deemed to delegate to the Ballet, its agents or employees the authority to consent to the withdrawal of any life-sustaining equipment or procedure, food or hydration.

This delegation is made subject to the following conditions:

1.) The Ballet makes reasonable attempts to personally contact me/us to obtain my/our consent in the event our Child requires any health care services while under the care or custody of the Ballet; and
2.) This delegation is to be exercised in good faith and in the Child's best interests.

This Consent is effective for the period of August 1, 2019 through July 31, 2020 for the Child's participation in classes, activities and performances with the Ballet, wherever located.

I've read the above and agree.

Payment Policy

Centre Ballet
2019-2020 Tuition Payment Method

The payment plan options:
_ Plan A: Full-year payment due August 1 (prorated) (10% savings)
_ Plan B: Semester payments due August 1 (prorated) and January 1 (5% savings)
_ Plan C: Nine installment payments due the 1st of each month starting
August 1 (prorated) through May 1st.

**PAYMENTS ARE LATE AFTER THE 10TH (Automatic $5 FEE FOR EACH LATE DAY)

The payment options: __ Cash __ Check ( at front desk )

*Paypal (automatic payment)

(Card # __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Exp. __ __ / __ __ CVC __ __ __
NOTE: For the Automatic Withdrawal and Charge options, payments
will be processed on the due date for the tuition payment due date.
All students opting for Plan B or C and paying with cash, check or with Centre Ballet from checking must have a currently valid credit card number on file in the event a payment is not received by the 11th of the month. Centre Ballet will submit the charge to the credit card on the 12th of the month in the event of non-receipt of payment.
Charge (MasterCard, VISA , American Express or Discover)

I've read the above and agree.

Consent to release/use of student photos/information

I authorize and consent Centre Ballet, LLC, the use and reproduction of any and all photographs taken of my students for samples, displays, promotions, advertisements and other legitimate purposes without compensation.

I authorize Centre Ballet to include my name, address, email, phone number, student name and class level in a student/parent directory.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments