Ballet at Bement Registration 2017-2018
Please complete the following form to register for Ballet at Bement.  If you have any questions about the program or are unsure of which level to enroll your child, please contact the instructor, Julia Chen, at yu629@yahoo.com.

Ballet at Bement
94 Old Main Street, P.O. Box 8, Deerfield, MA 01342 • 413.774.7061
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Student Information
Student's Name *
Age as of September 1, 2017 *
Date of Birth *
MM
/
DD
/
YYYY
Academic Grade (2017-2018 school year) *
Student's primary address *
Please describe any previous ballet experience *
no previous experience
1
2
3
4
5 or more
Number of years studied?
How many times per week?
Ballet Class Information
Please choose the class you would like to enroll in and the length of the enrollment. There will be no classes on Bement school holidays. Please check with instructor about classes on early dismissal days.
My child will be attending: *
Please check all terms your child will be enrolled for: *
Required
Parent Contact Information
Parent/Guardian Name *
Email *
Home phone # *
Cell or business phone # *
Emergency contact name *
Emergency contact phone # *
Other Information
I understand that I am enrolling my child(ren) in a physically demanding activity; neither I nor any representative of me or my children shall hold The Bement School, Julia Chen, or any other teachers responsible in the event that my children become injured during any activities associated with Ballet at Bement. *
Please list any allergies or other health concerns that may be helpful information to those in a supervisory position with your children.
Payment Options
You will see a link for online payment on the confirmation page after you submit this form.

If paying by check, please make checks payable to The Bement School and mail to Ballet at Bement, The Bement School, 94 Old Main Street, P.O. Box 8, Deerfield, Massachusetts 01342.

Pre-Ballet                 $110 per term; $300 for 3 terms
Primary & Ballet I    $120 per term; $320 for 3 terms
Ballet II, III, IV           $220 per term; $610 for 3 terms
Ballet V, VI*              $330 per term; $900 for 3 terms
Ballet Int/Adv*         $330 per term; $900 for 3 terms

    *For students joining twice per week, please pay $230 per term, $630 for 3 terms.
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