| Please Print |
Date: |
Student's Full Name:
Last First Middle Initial |
| Student's Age: |
Birthdate: |
| Student's Street Address: |
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| City: State: Zip: |
| Day Phone: |
Evening Phone: |
| Home E-mail Address: |
| Father's Name: |
Mother's Name: |
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| Occupation: |
Occupation: |
| Employer/Firm: |
Employer/Firm: |
| Address: |
Address: |
Work email:
Work Phone:
Cell Phone: |
Work email:
Work Phone:
Cell Phone: |
How did you hear about Virginia Ballet Company?
(Newspaper, Yellow Pages, Website, Parktakes, Former Student, Friends, Other) |
| Student's number of years trained: Ballet Pointe School |
| Please advise if your child is taking any medication(s): |
| Does your child have any allergies we need to be aware of? |
| Workshop Level Enrolled In: |
Session Enrolled In: |
I give permission for my child to attend class at Virginia Ballet Company and School.
I agree not to hold Virginia Ballet responsible for any injuries suffered by my Child while at the Virginia Ballet Company and School.
I also authorize the personnel of Virginia Ballet to obtain emergency medical treatment for my child in the event it is necessary. |
Emergency Contact Person:
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Emergency Number:
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| I understand that payment is due at registration and that a fee of $25.00 will be levied for checks returned by the bank for insufficent funds. I further understand that there will be NO Refunds for classes. I have read, understand and agree to the terms of the Virginia Ballet Company and School Enrollment Agreement, Standard Code of Conduct, Dress Code, Attendance, Production and Tuition Policies. |
| Signature of Student (Parent or Guardian if Student is a Minor): |
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| Below Space Is For Office Use Only: |
| Tuition Payment: |
Session One Payment:
Date Amount Paid |
Session One Number of Classes: |
Session Two Payment:
Date Amount Paid |
Session Two Number of Classes: |
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Please fill out and print form to submit to office with payment before or on the first day of class.
Completed forms may be mailed to:Virginia Ballet Company
Attention: Registration Office
5595 Guinea Road, Fairfax, Virginia 22032
For Additional Information or If You Have Any Questions Please call (703) 249-8227 |