Student Registration Form

Student Registration Form

Fill out the form carefully for student registration
Student Name*

First NameMiddle NameLast Name
Birth Date *

MonthDayYear
Gender
Years of Study
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail for School Communications*
example@example.com
E-mail for School Communications #2
example@example.com
Parent or Guardian Name*

First NameMiddle NameLast Name
NAME OF PERSON RESPONSIBLE FOR PAYMENT*

First NameLast Name
E-mail for TUITION INVOICING*
example@example.com
Phone # Number for Student Inquiries*
Best Phone # for Emergency Contact (in case of illness who do we contact)*
Other Phone #
Class Level - Fall 2022/Spring 2023*
Which Day will student take DM 3/4 class?*
Which Day will student take Prep class?*
Which Day will student take Ballet I (BI) class?*
Which Day will student take BIIA class?*
BIIB (2 Classes per wk) Class Schedule:

Tuesdays 5:00-6:00pm & Thursdays 4:15-5:15pm
Which Day/s will student take ballet class
If options above are not accurate for your student, please indicate days in the text box below
Enter the day/s your student will take ballet class if not indicated above or if not following the regular curriculum requirement for their level.
Additional Classes (i.e. Contemporary, Jazz, Tap, Partnering)
By signing below, I agree to hold harmless the staff, teachers, directors and board members of Kingsport Ballet in the event that my child is injured in the course of his/her activities and classes at Kingsport Ballet. With my signature I acknowledge that I understand that participation in dance can be strenuous and challenging and could result in accidental injury.
Signature*

Clear
Should be Empty: