Providence Ballet

 Registration 2010-2011

 Providence Ballet 

2010-2011 , R E G I S T R A T I O N   F O R M

 

194 Oxford St. Providence, RI 02905 (401) 861-4842 ProvBallet@cox.net

3355 South County Trail. East Greenwich, RI 02818 (401) 886-7827 

 

Please Print 

 

 

Child’s name______________________________________________DOB_________________________

 

Parent/Guardian _________________________________________________________________________

 

Address________________________________________________________________________________

 

City___________________________________State______________________Zip___________________

 

Telephone # _________________cell # ____________________Emergency #________________________

 

 

E-mail_________________________________________________________________________________

 

REGISTERING FOR

 

Creative Movement, Wed. (EG) ___ Wed. (Prov) __ Sat. (EG) __

 

Pre-Ballet, Mon. (EG) ___ Wed. (Prov)__Sat. (EG) __ 

 

Ballet I, Mon. (EG) __ Sat. (EG) __  Ballet I/II, Thurs. (Prov) __ Ballet II, Sat. (EG) __ 

 

Ballet II/III, Wed. (EG) __ Ballet III/IV, Mon. (Prov) __ Thurs. (Prov) __

 

Ballet IV, Mon. (EG) __  Thurs. (EG) __ Ballet V, Tues. (EG) __  Thurs. (EG) __

 

Inter. I/Pointe, Thurs. (EG) __Inter. I/II, Tues. (Prov) __  Sat. (Prov) ____

 

 Inter. Adv. Ballet, Mon. (Prov) __ Wed. (Prov) __ Sat. (Prov)  __

 

Beg. Pointe, Tues. (EG) __  Thurs. (EG)__

 

Inter.I/II Pointe,  Tues. (Prov) __Inter. II Pointe, Sat. (Prov) __

 

Inter. Pointe, Mon. (Prov) __

 

Jazz II,Wed. (EG)__

 

Modern I, Mon. (EG) __Modern II, Wed. (EG) __ Thurs. (Prov) __

 

Inter. Modern, Wed. (Prov) __


 

                                                                     Tuition, ___________

 

                              Registration/insurance fee $40.00 ______   Non refundable payable once a year per family 

 

                                                                                                                                                          

 

Payment Method; Check/Cash  credit card:  check ____ Cash____ Visa, Master card, or discover _______

 

 

Credit card # _______________________________________________expiration date: _______________ 

                                         

 

 

Disclaimer / Waiver of Liability

 

  The undersigned acknowledges that the participation in dance education involves strenuous physical activity and that Providence Ballet, Inc. and its employees will not be held responsible for injury of any kind as a result of this participation. Also, Providence Ballet, Inc. and its employees will not be responsible for administrating prescription medication. For the common welfare, it is necessary to disclose any conditions, physical or otherwise, that may affect the undersigned and/or other participants

 

 

 

Signature of Parent/Guardian _________________________________________date _______________

  

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