Dance Class Registration

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Student's Name *

Option 1

Clear selection

Student's Birthdate *

YYYY

Student's Age *

Parent / Guardian Name *

Mobile Phone *

Additional Preferred Number

Email *

Please share anything to be aware of (medical, etc.) regarding your child:

Please provide ALL persons authorized to pick up your child:

Ballet Imagination will only release students to people on this list. Notify Neil Mitchell at 718.290.6529 in the event of any changes.

Authorized Pickup 1: Name / Phone

Authorized Pickup 2: Name / Phone

Authorized Pickup 3: Name / Phone

What class are you signing up for? *

Please pick the class your child would like to participate in.

Ballet Level 1 (Thu 3:30)

Ballet Level 2 (Tue 4:00)

Ballet Level 3 (Thu 4:30)

Advanced Level Ballet (Tue 5:00)

Summer Musical Theater Dance Intensive

Spring Dance Intensive

Required

What semester? *

Please pick which semester you would like to join.

Fall

Spring

Summer

Full Year

Required

Release form

By signing this form I hereby release Ballet Imagination and its ownership and staff from any liability which may result from accident or injury.

Electronic Signature & Date

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