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.
Email *
Student's Name *
Age *
Birthday *
Home Address (Street, City, State, Zip) *
Student Email (Optional)
Student Phone (Optional)
School District
Mother's Name
Mother's Cell Phone
Mother's Email *
Mother's 2nd Email
Mother's Occupation
Mother's Employer
Mother's Address if Different from Student
Father's Name
Fathers Cell Phone
Father's Email
Father's 2nd Email
Father's Occupation
Father's Employer
Father's Address if Different from Student
Emergency Contact Name
Emergency's Contact Phone Number
Student Food Allergies
Student Drug Allergies
Please include any information which might be helpful in case of emergency
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 *
Phone *
Policy/Group/Subscriber Number *
Subscriber's Name *
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 *
Date *
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.
Parent Signature or Student if over 21 *
Date *
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