Payment/Fee

Enrollment Date

Check #

Placement Level

Check Date

Contact Information
Please print clearly

Student:
 New Student Returning Student

Gender:
 Male Female

Last (required)

First (required)

Middle

Address

City

State

ZIP

Home Phone (required)

Cell Phone (required)

Primary Email (required)

Age

Date of Birth

Academic School

Current School Grade

Previous Training

Mother/Guardian:

Name

Email

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Father/Guardian:

Name

Email

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Person Responsible for tuition payment(s):

Name

Email

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Emergency Contacts / Medical Information

Contact 1

Relationship

Cell Phone

Contact 2

Relationship

Cell Phone

Personal Physician

Office Phone

Medical Conditions & Medications

Previous hospitalization and surgeries:

All students, new and returning,must pay a registration fee of $25 per student due with the first payment.

A special 5% full payment tuition discount is available if tuition for the entire year is paid in September.

Students are registering for the full school year and will be responsible for tuition for the full school year. Only exception is students in Creative Movement and Pre-Ballet who have the option to enroll for the fall, spring, or both semesters.

Full year payment is due by the student’s first class of September. Semester payments are due by the student’s first class of September and January. Monthly payments are due by the student’s first class of each month.

A grace period of 5 days will be honored. Payments received after the 5-day grace period will result in a $25 late fee regardless of reason.

Returned checks will be assessed a $30 service charge.

A 10% sibling discount is offered. The student in the highest level will pay full tuition and younger sibling(s) receive 10% discount on their tuition.

Students with 2 consecutive months of outstanding tuition will not be allowed in class until their account is paid.

All students will receive a student handbook and school calendar at the mandatory Student/Parent Orientation meeting.

Payment Information

Payment Plans - Choose one option
 Full year Payment - 1 payment due September with 5% discount. Semester - 2 equal payments due September & January. Monthly - 9 equal payments due September to May

Payment Options - Choose one option
 Check or cash. PayPal – change payment type to SENDING TO A FRIEND to avoid fees Credit Card - Convenience fee of 5% of the payment, amount (minimun $1 fee) will be assesed

Reminder: A $25 registration fee per student will be added to your first payment

Credit Card Authorization

Select the type of credit card
 Visa MasterCard Discover

Credit card account number

Security code (Visa & MasterCard 3 digits code on the back)

Expiration Date

Name on Card

Phone

Billing Address

I authorize Kansas School of Classical Ballet to automatically charge my credit card according to the payment plan selected above, I agree to the 5% convenience fee (minimum $1 fee) that will be assessed for every credit card transaction. SCB will keep my credit card information on file. I will be responsible to update SCB on any credit card changes during the school year.

Signature

Date

Electronic Signature
 I Accept Not Accept

Check box for electronic signature - Please type your first and last name in the signature field.

I understand that checking this box constitutes a legal signature confirming that I aknowledge and agree to the above term of acceptance.

Making a gift to Kansas School of Classical Ballet

All gifts are important and help promote our mission to provide the finest training available to students interested in learning the art of ballet.

Thank you for your investment in our young artists. In addition to tuition, please consider making a donation in support of our talented students in the amount of:

 $10

 $25

 $50

 $100

 $250

 Other

Method
 Check or cash enclosed Combine with my credit car tuition payment

KSCB is a not-for-profit 501(c)(3) organization and all gifts are 100% tax deductible. Donation receipt provided upon request.

Liability Waiver

I agree to the terms of enrolling in Kansas School of Classical Ballet. I understand there is a risk of harm/injury inherent in dance.

I represent that the student is in good health and proper physical condition. If I believe conditions are unsafe, I will immediately discontinue participation. I understand dance involves risks of harm which may be caused either by students’ own actions or inactions, others participating in the class, or the conditions in which the dancing takes place. I further acknowledge there may be risks not known to me or readily foreseeable at this time, yet I fully accept and assume all such responsibility for losses, cost, and damages incurred as a result of participation in Kansas School of Classical Ballet and hereby covenant that I will hold Kansas School of Classical Ballet, including instructors and staff, blameless for any harm/injury that occurs through no intention or fault of their own. In case of medical emergency, I give permission to the staff of Kansas School of Classical Ballet to secure medical treatment. I agree to be responsible for any and all charges incurred in this situation.