REGISTRATION FORM

Student Name:

Phone Number:

Address:

Parent/Guardian Name:                                          Work #:                              Cell #:

Medical Information/Allergies:

Doctor's Name:                                                       Phone #:

Years of Training:

Current Level:

Birth Date:

How did you hear about us? _________________________________________________________ ________________________________________________________________________________

Participation Release: Parents/Guardians understand that ballet classes are not without risk of physical injury. Parents/Guardians full assume such risk, including the full cost of medical treatment. Mountain West Ballet and/or its agents are not responsible or liable for any injury while on these premises. ________________________________________ Parent/Guardian Signature (Participant if over 18) _______________________ Date