BalletIdahoAcademy 501S.

8thStreet Boise,ID83702

2013-2014 Registration Form

Student and Parent Contact Information Billing Name Address City Home Phone Mother/Guardian Father/Guardian Student 1 Name Birth date Student 2 Name Birth date Student 3 Name Birth date
Class Enrollment Information

Phone: (208)3430556 Fax: (208)4243129

State E-Mail Hm Ph Hm Ph

Zip Cell Cell

Gender

Recital

Yes

No

Gender

Recital

Yes

No

Gender

Recital

Yes

No

Student

Class/Fee Description

Day/Time

Tuition

Discount

Proration

Total

I am interested in being contacted about Guild membership and volunteer opportunities I am not interested in being contacted about Guild membership and volunteer opportunities Payment Method: Credit Card Check # _________

Subtotal Registration Total Due Cash

Credit Card # ________________________________________ Sec Code _____ Exp Date ___/___

Payment Option:

Pay in Full

2 Payments

4 Payments

8 Payments

AutoPayAuthorization
IauthorizeBalletIdahotowithdrawpaymentsfromtheabovereferencedaccountinaccordancewithmyselectedpaymentplanuntiltuitionispaidinfull. Iunderstandthatpaymentduedatesarelocatedonthe20132014academyEventCalendar. IunderstandthatthisauthorizationwillremaininfullforceandeffectuntilIprovidewrittennoticeofitscancellationtoBalletIdaho. Initial X _______

Parent Signature: _____________________________________

Date: _______________

Approved by: ________

BalletIdahoAcademy 501S.8thStreet Boise,ID83702

2013-2014 Medical & Liability Release

Emergency Contact Information Emergency Contact 1 Emergency Contact 2 Emergency Contact 3 Emergency Contact 4 Medical Information Dr. Name Hospital Pref. Insurance Co. Student 1 Info Student 2 Info Student 3 Info Please Read, Initial and Sign The Following Release, Waiver and Consent Form Policy Number Phone
Hm Ph Hm Ph Hm Ph Hm Ph Cell Cell Cell Cell

Phone: (208)3430556 Fax: (208)4243129

MEDICAL WAIVER: I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency. X________ MEDICAL CONSENT: In the event of injury, I hereby authorize the program officials of the Ballet Idaho Academy to arrange for medical services as may be deemed reasonable and necessary to the welfare of the injured, and I do hereby release the Ballet Idaho Academy and all others from all liability in taking action, including all action which may be contrary to personal religious beliefs. I, the undersigned, have read this Release and Consent to medical treatment and understand all its terms. I execute it voluntarily and with full knowledge of its significance. X________ LIABILITY RELEASE: I do hereby agree to release the Ballet Idaho Academy and all other cooperating agencies, employees, officials, or managers thereof, from all liability for damages by reason of injuries or property damages that may be sustained as a result of participation in this program. X________ PHOTO RELEASE: I, the undersigned, hereby give Ballet Idaho, its agents, and/or assignees permission to use the photographs, motion pictures or any reproductions of the above students physical likeness taken of me in any manner it deems proper. I relinquish all rights, title, and interest I may have in the finished pictures, negatives, and copies. I waive the right of prior approval to any finished products, advertising copy, or other matter or use that may be applied, and hereby release Ballet Idaho, it agents, and/or assignees from any and all claims from damages of any and all kinds based on the use of said material. I hereby warrant that I am a parent or legal guardian of the subject of photography, who is under eighteen years of age, and am competent to act in his/her behalf insofar as the above is concerned. X________

I have read and I agree to all published registration and tuition polcies for the 2013-2014 Academy year.
X________

Parent Signature: _____________________________________

Date:

Approved by: ________