Student Registration Form

Student Registration Form

Fill out the form carefully for student registration
Student #1 Name

First Name Middle Name Last Name
Birth Date

Month Day Year
Gender
Years of Study
Address

Street Address

Street Address Line 2

City State / 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 Name Middle Name Last Name
NAME OF PERSON RESPONSIBLE FOR PAYMENT

First Name Last 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/s will student take ballet class (only complete if there is a choice of days for your child's level)
If options above are not accurate for your student, please indicate days in the text box below
Enter the days your student will take 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 *

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