Registration 2010-2011
Providence Ballet 2010-2011 , R E G I S T R A T I O N F O R M
2010-2011 , R E G I S T R A T I O N F O R M
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 _______________
