EmailMe Form - ABA Summer Workshop Registration

Dancer Information

Student Name *

First Last

(Please use a separate form for each student.)

Which summer workshop will you be attending? *

Pre-Ballet/Ballet Fundamentals

Ballet I

Ballet II

Ballet III

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Student's Email

Student's Cell Phone

### - ### - ####

Student's Home Phone

### - ### - ####

Student's Date of Birth *

MM / DD / YYYY

Age *

Height *

Gender *

Boy

Girl

Other

Ethnicity *

Academic School *

Grade *

Physician's Name *

Physician's Phone *

### - ### - ####

Does the student have any medical concerns of which we should be aware? *

Dance Background Information

Current Dance Studio *

Dance Class Level *

How many classes a week are you currently taking? *

Please explain your dance training. *

Please explain your performance experieince. *

Emergency Information

Emergency Contact Name *

First Last

Relationship to Student *

Phone *

### - ### - ####

Guardian Contact #1

Name *

First Last

Relationship to Student *

Email *

Cell Phone *

### - ### - ####

Work Phone

### - ### - ####

Guardian Contact #2

Name

First Last

Relationship to Student

Email

Cell Phone

### - ### - ####

Work Phone

### - ### - ####

Other Information

How did you hear about the Academy of Ballet Arts Summer Intensive? *

Please read and sign below.

By your signature below, you acknowledge that photographs and/or video may be taken of the student, and that The Academy of Ballet Arts, Inc. may use such media and/or likenesses in print, on the Internet, and/or for training purposes. If you have an objection to the use of your student’s image, please contact The Academy of Ballet Arts, Inc. before completing this form.

The Academy of Ballet Arts, Inc. does not discriminate on the basis of race, color, gender, marital status, age, sexual orientation, disability, religious preference and national or ethnic origin.

Signature: please print your full name. *

Date Time *

MM / DD / YYYY

Dancer Information

Dance Background Information

Emergency Information

Guardian Contact #1

Guardian Contact #2

Other Information

Please read and sign below.

**To avoid duplicate submissions, please only click "Submit" once. It may take a moment for the form to process and move to the next page.**

To avoid duplicate submissions, please only click "Submit" once. It may take a moment for the form to process and move to the next page.