Payment

Enrollment Date

Check #

Placement Level

CC Conf #

Contact Information–

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

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:

Kansas School of Classical Ballet or its employees is not responsible for personal injuries and damaged/lost property. I give KSCB my permission to use dance photos of my child for advertising purposes including newspapers, the KSCB website and Facebook page, and email. I also understand the school’s policies as outlined and that I am responsible for the full tuition payment which is due on or before the first day of classes.

Parent/Guardian Signature

Date

Accept Electronic Signature Registration Workshop
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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.

Your Complete Name(required)

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