Student Name *

First Name

Last Name

Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Checkbox *

Tuesdays 5:30-6:30, 10/21, 10/28, 11/4, 11/11

Policies & Procedures *

I have fully read through, understand and will follow CBM's Policies & Procedures.

I have read and accept CBM's Procedures & Policies.

Medical Release *

Medical Release and Authorization: As legal guardian of the child listed on this form I hereby consent for him/her to participate in classes conducted by the Children’s Ballet & Movement Co. Recognizing that any activity involving movement can create the possibility of injury. I will not hold any personnel, officers, agents or instructors liable for any injury that may occur before, during and after class or on the Children’s Ballet & Movement Co. premises. I confirm that my child is in good health and I authorize simple first aid if necessary. I also understand that I am fully responsible for the total tuition session I registered for unless my child is unable to participate for medical reasons. In which case I will provide a signed medical notice from his/ her doctor.

I have read and accept Medical Release and Authorization

Photo/Audio/Video/Social Media Release Authorization *

Photo/Audio/Video/Social Media Release Authorization: I hereby irrevocably consent to and authorize the reproduction, publication and/any other use by The Children’s Ballet & Movement Co., his/her licensees and assigns, of the photographs/audio/video, in any medium and for any lawful purpose, including illustration, promotions, advertising, social media or web content, without any royalty or compensation to me. I assign to The Children’s Ballet & Movement Co. any and all rights of ownership to the photographs/audio/video, the transparencies or digital files thereof, and agree that The Children’s Ballet & Movement Co. has full right of lawful disposition in any manner. I waive any right to notice, inspection, or approval of any use of the photographs/audio/video which The Children’s Ballet & Movement Co., may make or authorize, and I release The Children’s Ballet & Movement Co., and his/her licenses and assigns, from any claim or liability arising from or in connection with The Children’s Ballet & Movement Co.’s us of the photographs/audio/video or any alteration, processing or use thereof in composite form, whether intentional or otherwise. CHECK ONLY ONE BOX BELOW.

I have read and accept Photo/Audio/Social Media Release and Authorization.

I have read and deny Photo/Audio/Social Media Release and Authorization.