Inland Pacific Ballet Academy Registration Form
Registration Form 2019-2020 Academic Year - Fall, Winter, Spring
Please go to Front Desk to pay $35 Yearly Registration.
Note: Important information is communicated via email.
Student's Name *
Your answer
Age *
Your answer
Birthday *
MM
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DD
/
YYYY
Home Address (Street, City, State, Zip) *
Your answer
Student Email (Optional)
Your answer
Student Phone (Optional)
Your answer
School
Your answer
School District
Your answer
Mother's Name
Your answer
Mother's Cell Phone
Your answer
Mother's Email *
Your answer
Mother's 2nd Email
Your answer
Mother's Occupation
Your answer
Mother's Employer
Your answer
Mother's Address if Different from Student
Your answer
Father's Name
Your answer
Fathers Cell Phone
Your answer
Father's Email
Your answer
Father's 2nd Email
Your answer
Father's Occupation
Your answer
Father's Employer
Your answer
Father's Address if Different from Student
Your answer
Emergency Contact Name
Your answer
Emergency's Contact Phone Number
Your answer
Student Food Allergies
Your answer
Student Drug Allergies
Your answer
Please include any information which might be helpful in case of emergency
Your answer
Medical Treatment Authorization
I personally, as the participating student, or the parent or guardian of said student, authorize any emergency medical treatment that may be required for me/my child/ward during participation of this program. My medical insurance if offered through:
Insurance Company Name *
Your answer
Phone *
Your answer
Policy/Group/Subscriber Number *
Your answer
Subscriber's Name *
Your answer
Indemnity/Hold Harmless Agreement
I agree to indemnify and hold harmless Inland Pacific Ballet Academy, their agents, officers and employees from and against any and all suits, claims, and expenses including attorney fees by reason of the liability imposed by law upon Inland Pacific Ballet Academy for damage because of bodily injury sustained as a result of my daughter's/son's participation in classes, rehearsals, master classes, and recital. Furthermore, I understand Inland Pacific Ballet Academy cannot be held responsible for lost or stolen property.
Parent Signature or Student if over 21 *
Your answer
Date *
MM
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DD
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YYYY
Important Policies
I have read and agree to adhere to the rules, regulations, policies, dress code, and tuition policies of Inland Pacific Ballet Academy as shown in the Parent/Student Handbook.
http://www.ipballet.org/pdf/ParentStudentHandbook_IPBA.pdf
Parent Signature or Student if over 21 *
Your answer
Date *
MM
/
DD
/
YYYY
Submit
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