Geiger Ballet Student Registration Form ~ Summer 2013

Student’s Name ______Birth Date ______

Address ______City, State, Zip ______

Current Ballet School ______

Previous Training: Total Years Ballet Study ______On Pointe? ______Years on Pointe ______

IN CASE OF EMERGENCY CONTACT:

Name ______Email ______

Phone ______Alternate Phone ______

MEDICAL & RISK WAIVER

I hereby give my permission for my child to participate in the activities of the Geiger Classic Ballet Academy summer programs. I release the Geiger Classic Ballet Academy, its Owners and Employees from any responsibility for any accident or injury that could occur. I have alerted the staff of any problems or medical restrictions that my child has. I am aware that any dietary concerns should be covered by myself and controlled by providing a proper sack lunch and snacks.

ANY CONCERNS? ______

CONSENT

I understand and allow any photo and video materials with my child’s participation to be free for further use by the Geiger Classic Ballet Academy.

GUARDIAN’S SIGNATURE ______DATE ______

Classes you are registering for:

Apprentice Camp ______Week 1 6 $______

Week 1 / July 8-12
Week 2 / July 15-19
Week 3 / July 22-26
Week 4 / July 29-Aug 2
Week 5 / August 5-9
Week 6 / August 12-16

Junior Intensive Camp ______Week 2 3 $______

Senior Intensive Camp ______Week 4 5 $______

Extended Program ______Week 1 2 3 4 5 6 $______

Registration Fee $ 10.00

Total $______

REGISTRATION AND FEES ARE DUE BY JUNE 8, 2013. ALL FEES ARE NON-REFUNDABLE.

FEES ARE NON-TRANSFERABLE TO ANOTHER PROGRAM ONCE REGISTRATION HAS BEEN SUBMITTED.

Payment to GCBA can be made by: o Cash o Check o Visa o MC

Credit Card # ______Exp Date ______

For more information call us at 248-334-1300 or email .
Please mail completed form along with full payment to:
Geiger Classic Ballet Academy ~ 782 Denison Court ~ Bloomfield Hills, MI 48302