Dance Class Registration
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Student's Name *
Student's Birthdate *
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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.
Required
What semester? *
Please pick which semester you would like to join.
Required
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
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