Children's Ballet with Ashley Driggers-- Children's Class Registration for Harlem Arts Council
Please complete this form if you would like to register for the Harlem Arts Council's youth or adult class referenced above. Please read the information on each class's webpage for more information and for age restrictions https://www.harlemartscouncil.org/art-classes-camps. We thank you in advance for being part of the arts in our community. Please be sure to contact Education Officer Tina Pilgrim at educationofficer@harlemartscouncil.org should you have any questions regarding classes or registration.

Return to the class webpage to pay.

Complete one form per student.

Please confirm space availability with Miss Ashley or Tina Pilgrim before registering.
Email address *
What is today's date? *
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Please enter the student's last name(s). *
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Please enter the student's first name(s). *
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Please enter the student's nickname or preferred name if different than above.
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What is the child's date of birth?
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What is the child's gender?
Please enter the guardian's last name(s). *
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Please enter the guardian's first name(s). *
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What is the guardian's phone number?
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Does your child have any allergies or medical conditions that we need to be aware of. Please describe.
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Ashley's classes are offered on Mondays, ages 4 to 5 from 4:30 pm to 5:00 pm, ages 6 to 8 from 5:00 pm to 5:30 pm, ages 9 to 11 from 5:30 pm to 6:00 pm. Which classes will your child be attending?
Which months will your child be attending?
What is your mailing address? (Example: POB 457, Harlem, Ga 30814) *
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Please list three emergency contacts for your child (Name, phone number, and relationship: example Martha, 706-555-5555, grandmother) *
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Please list the names of anyone authorized to pick up your child from class. (Name, phone number, and relationship: example Martha, 706-555-5555, grandmother) You can type same as above if this is the same list as your emergency contacts. *
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Is there anything we need to know about the learning abilities of your child? Please explain.
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Insurance & Waiver of Treatment: Harlem Arts Council does not carry medical insurance for its students. It is required that all students be covered by their own family insurance policy and it is understood that if injury does occur, the student's own policy is your only source of reimbursement. My signature below indicates my certification that I have medical insurance on the dancer listed above and will maintain continuous medical coverage while he/she dances at Harlem Arts Council. I also authorize Harlem Arts Council and its owners, employees, directors, etc. to use standard first aid procedures on the dancer listed above and to consent any other medical procedure that I deemed necessary in the case of an emergency. Furthermore, I certify that I personally and/or my medical insurance carrier will be responsible for all expense which are incurred in relation to any injury sustained during any Harlem Arts Council related activity including but not limited to a Harlem Arts Council class, competition, show, performance, etc. (Please list your medical coverage info below. Make sure that you informant Harlem Arts Council if this info changes.) What is your insurance company's name for your child's health insurance? *
Your answer
Insurance & Waiver of Treatment: Harlem Arts Council does not carry medical insurance for its students. It is required that all students be covered by their own family insurance policy and it is understood that if injury does occur, the student's own policy is your only source of reimbursement. My signature below indicates my certification that I have medical insurance on the dancer listed above and will maintain continuous medical coverage while he/she dances at Harlem Arts Council. I also authorize Harlem Arts Council and its owners, employees, directors, etc. to use standard first aid procedures on the dancer listed above and to consent any other medical procedure that I deemed necessary in the case of an emergency. Furthermore, I certify that I personally and/or my medical insurance carrier will be responsible for all expense which are incurred in relation to any injury sustained during any Harlem Arts Council related activity including but not limited to a Harlem Arts Council class, competition, show, performance, etc. (Please list your medical coverage info below. Make sure that you informant Harlem Arts Council if this info changes.) What is your insurance policy number for your child's health insurance? *
Your answer
Insurance & Waiver of Treatment: Harlem Arts Council does not carry medical insurance for its students. It is required that all students be covered by their own family insurance policy and it is understood that if injury does occur, the student's own policy is your only source of reimbursement. My signature below indicates my certification that I have medical insurance on the dancer listed above and will maintain continuous medical coverage while he/she dances at Harlem Arts Council. I also authorize Harlem Arts Council and its owners, employees, directors, etc. to use standard first aid procedures on the dancer listed above and to consent any other medical procedure that I deemed necessary in the case of an emergency. Furthermore, I certify that I personally and/or my medical insurance carrier will be responsible for all expense which are incurred in relation to any injury sustained during any Harlem Arts Council related activity including but not limited to a Harlem Arts Council class, competition, show, performance, etc. (Please list your medical coverage info below. Make sure that you informant Harlem Arts Council if this info changes.) In the case of an emergency, do you authorize an agent of the Harlem Arts Council to seek medical attention for your child? *
Waiver of Liability: Safety is the main objective, but any activity involving motion has a chance of accidental injury. I, the undersigned parent or legal guardian of the dancer listed above, do hereby give permission for the aforementioned persons to participate in any and all classes, programs, shows and events offered by or attended by Harlem Arts Council. I accept all risks associated with that participation and understand that there is a full possibility of serious physical illness or injury. I here by convent not to sue and waive, release forever discharge any and all rights and claims for damages, which may arise now or in the future against Harlem Arts Council and its officers, owners, directors, employees, the owner of the facility in which Harlem Arts Council exists and/or other assigned representatives or volunteers from any and all liability and any and all damages and/or injures which may be sustained or suffered by the dancer listed above while participating at or for Harlem Arts Council. Click YES to accept. *
Rules and Regulations: Each child must come on time and prepared to each dance class. He/she must wear the appropriate dance attire such as leotard, skirt, tights, and ballet slippers. Hair should be pulled back away from the child’s face. If failure to come prepare the child may be asked to sit out (under special circumstance a child may come in “street” clothes). We ask that all children utilizes the facilities BEFORE dance class. Classes are short and we use every minute to teach and interruptions can hold us up. By signing below you agree to all terms and conditions. Gum is prohibited in all dance classes. To reduce the aide of choking a child must never have gum or any other object in their moth. Furthermore, I hereby give my permission to Harlem Arts Council to use photographs and/or videos of the dancer listed above as deemed appropriate for the promotion of Harlem Arts Council. Each class will be held on the designated date/time according to the child’s age. Please make sure each session you have signed your child up for has been paid in full before class. The non-refundable registration fee portion is nulled if the dance session has not been paid. As always, parents/guardians are encouraged to teach their child to be independent and therefore no parents are allowed in the class while classes are being taken place. There are designated seating areas outside, please use them. Signing below states you have read and understand the above rules and regulations. Click YES to accept. *
Dance Class Payment(s): I am fully aware and by signing below is my recognition that I am responsible for paying each dance class per month BEFORE each new month of dance class throughout the dance season of 2019-2020. If not paid BEFORE the first dance class of each month my child will be automatically removed from the dance class roster until full payment. Click YES to accept. *
Tentative Dates for the 2019-2020 Dance Season:Classes will follow the Columbia County School Calendar and Holiday ScheduleAugust 12– Classes beginSeptember 2– Labor Day (No Dance Class)October 14-Fall Break (No Dance Class)November 25-November 29– Thanksgiving Break (No Dance Class)December 23-January 3– Christmas Break (No Dance Class)January 6–Dance Classes ResumesJanuary 20– Martine Luther King, Jr. Holiday (No Dance Class)February 17-Student Winter Break/President’s Day (No Dance Class)April 6-10-Spring Break (No Dance Class)April 13-Dance Classes Resumes**April 27-Last Day of Dance ClassBloomin’ In the Arts Festival-Harlem, GA:TBD***This date could change due to the number of students still out of town for Spring Break/Master’s Week*Dates will be announced closer to event day. Each class will participate in showcasing their skills in a performance at this festival. More information and details to come. Click YES to accept. *
By typing your name below, you are confirming that the above information is correct, that you are a legal guardian of the child referenced, and that you are registering your child for children's ballet classes. Please type your electronic signature below (your full legal name) accepting the above terms and conditions. *
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A copy of your responses will be emailed to the address you provided.
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