Wise Ballet and Music Academy

1300 N. Hwy. 287 Decatur, TX 76234 (940) 627-7777, (940) 626-1124, wiseballetandmusic.com, e-mail:krsm272@aol.com

Registration and Release Form

Name of Dancer Enrolling_______________________________________Date of Birth_____________________________

Address____________________________________________City_____________________________Zip______________

Home Phone_______________________________________Cell Phone_________________________________________

Parent’s or Guardian’s Name(s)__________________________________________________________________________

Mother’s Phone____________________________________Father’s Phone______________________________________

*To receive emails and or text messages of announcements, class cancellations due to weather, and updates, please complete the following:

*Email address________________________________________ *Cell Phone Provider_____________________________

Emergency Contact _____________________________________ Phone Number_________________________________

Relationship to Student__________________________________Name of Licensed Physician_______________________

Physician’s Phone________________________________Hospital______________________________________________

Does Person Enrolling Have any Physical or Mental Handicaps?________________________________________________

If Yes, Please Explain__________________________________________________________________________________

Is the Person Enrolling on any Medication?____________ If Yes, What Type and for What Reason? _________________ ___________________________________________________________________________________________________

Does the Person Enrolling Wear Glasses or Contact Lenses?___________________________________________________

Any Other Physical Problems Not Mentioned Above?________________________________________________________

Student, Parent/Guardian agrees to the following policies:

A $20 annual registration fee, (see schedule for family rates), payment of tuition is due on the 1st class of each month. A $10 late fee will be added to payments received after the 10th of each month. There is a $25 service charge on all returned checks. Student, Parent/Guardian fully and unquestionably release Wise Ballet and Music Academy, the instructors, employers, employees, and authorized guests from any and all claims for any and all injuries, accidents and losses that he/she may receive. Student, Parent/Guardian understands that the whole of this agreement (liability) is effective from the date listed and will remain in effect indefinitely. Signature of Parent/Guardian or Authorized Co-Signer is necessary if the student is under the age of 18 years.

I have read and agree to abide by the policies outlined in both the brochure and class information handout. Student_______________________________________________________Date_________________________________

Parent/Guardian________________________________________________Date_________________________________

Co-Signer______________________________________________________Date_________________________________

For Office Use: Class Level(s)_____________________________Days_______________________________________Times____________________________________

Reg. Fee_______________________________________________________Tuition_______________________________________Date__________________________

Photograph and Publicity Release

I, ________________________, give my permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of Wise Ballet and Music Academy/Wise Performing Arts Guild and Wise Ballet and Music Academy/Wise Performing Arts Guild activities. I agree that Wise Ballet and Music Academy/Wise Performing Arts Guild has complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with the Wise Ballet and Music Academy/Wise Performing Arts Guild mission. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc for the use of such pictures, etc., and hereby release Wise Ballet and Music Academy/Wise Performing Arts Guild and its agents and assigns from any and all claims which arise out of or are in any way connected with such use. I have read and understood this consent and release. I give my consent to Wise Ballet and Music Academy/Wise Performing Arts Guild to use my name and likeness to promote the program, its fiscal agent, and/or their activities. ___________________________________________ __________________ Signature Date ___________________________________________ ___________________ Parent / Legal Guardian (if under age 18) Date I do not give my consent to Wise Ballet and Music Academy/Wise Performing Arts Guild to use my name and likeness to promote the program, its fiscal agent, and/or their activities. ___________________________________________ __________________ Signature Date ___________________________________________ ___________________ Parent / Legal Guardian (if under age 18) Date