Student Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Student Age
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Student Date of Birth
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MM
DD
YYYY
Name of Parent/Guardian
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Cell Phone 1
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Cell Phone 2
(###)
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Work Phone
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(###)
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Home Phone
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(###)
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Email Address
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Has the student had any serious physical injuries? If yes, please explain.
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Does the student have any mental, emotional or physical conditions that might affect or impair his or her ability to participate in dance training? If yes, please explain.
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Does your student have any allergies? if yes, please list.
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Insurance Company
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Policy Number
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Group Number
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If your student is new to FSBT, how did you hear about our program?
Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19 *
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The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.
First State Ballet Theatre has put in place preventive measures to reduce the spread of COVID-19; however, First State Ballet Theatre cannot guarantee that you or your child(ren) will not become infected with COVID-19 and First State Ballet Theatre cannot prevent you or your child(ren) from becoming exposed to, contracting, or spreading COVID-19 while attending class at First State Ballet. Furthermore, attending class at First State Ballet Theatre could increase your risk and your child(ren)’s risk of contracting COVID-19.
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending First State Ballet Theatre and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I acknowledge that it is not possible to prevent against the presence of the disease. Therefore, if you or your children choose to attend classes at First State Ballet or enter into the Facility you may be exposing yourself to and/or increasing your risk of contracting or spreading COVID-19. I understand that the risk of becoming exposed to or infected by COVID-19 at First State Ballet Theatre may result from the actions, omissions or negligent of myself and others, including, but not limited to, First State Ballet Theatre employees, volunteers and program participants and their families.
I agree that I am personally responsible for my safety and actions while attending classes at the First State Ballet Theatre. I agree to comply with all policies and rules for class instruction, including but not limited to all CDC policies, guidelines, signage, and instructions. Because multiple people will be attending classes from different households, I recognize that I and my children are at higher risk of contracting COVID-19. With full awareness and appreciation of the risks involved, I, for myself and on behalf of my family, spouse, estate, heirs, executors, administrators, assigns, and personal representatives, hereby forever release, waive, discharge, and covenant not to sue The First State Ballet Theatre and/or any member of the First State Ballet Theatre staff, employees, officers and directors (collectively the “Released Parties”) from any and all liability, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, or injury, including death, that may be sustained by me or my children related to COVID-19 whether caused by the negligence of the Released Parties, any third-party at the classes, or otherwise, while participating in any activity while in, on, or around the theatre or class instruction and/or while using any portion of the Facility.
I represent, warrant, and agree to the following:
I understand the symptoms of COVID-19 as described by the World Health Organization including but not limited to fever, shortness of breath, dry cough, fatigue, body/muscle aches or lack of taste or smell.
I will immediately inform First State Ballet Theatre if I, my minor student, or any member of my household, develops any of the aforementioned symptoms.
I will immediately inform First State Ballet Theatre if I, my minor student, or any member of my household, is diagnosed with COVID-19.
Furthermore, I will immediately inform First State Ballet Theatre if I, my minor student, or any member of my household, is knowingly exposed to anyone diagnosed with COVID-19.
FSBT Summer Children's Workshop Registration Terms and Conditions
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Payment Conditions
In signing this registration form for myself or on behalf of a minor student, I have read and understand the payment schedule set forth below.
In order to secure a place in the Summer Children's Workshop, a $50.00 non-refundable deposit is due by May 3, 2025. This deposit will be applied to the total tuition. TUITION IS NON-REFUNDABLE, with the exception of medical disability, with documentation from a doctor. NO REFUNDS OR CREDITS WILL BE GIVEN FOR CLASSES MISSED.
In signing this registration form for myself or on behalf of my minor student, I understand that the balance of the Summer Children's Workshop tuition is due on July 14, 2025 and that a $15.00 late fee will be applied to the tuition after this date.
Liability Release
I agree that my minor student or that I myself will abide by the polices of The School of First State Ballet Theatre. I consent to my minor student or myself participating in the school’s programs and activities. I recognize that in spite of the care of the school and its teachers that there is a possibility of injury during classes. In the case of such an injury to myself or my minor student, I release The School of First State Ballet Theatre, its teachers and associated personnel from all responsibility.
Medical Release
In the event of an injury to myself or my minor student which requires emergency medical attention, I permit the school to obtain such care and I promise to pay all associated costs upon receipt of the bill.
Publicity Release
I hereby authorize The School of First State Ballet Theatre the use all photographs and video of my minor student or myself for publicity including advertising and sales promotion.
I have read, understand and agree to the policies of The School of First State Ballet Theatre, Payment Conditions, Liability Release, Medical Release and the Publicity Release.