Student Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Cell Phone 1

(###)

###

####

Cell Phone 2

(###)

###

####

Work Phone *

(###)

###

####

Home Phone *

(###)

###

####

Please select from the following: *

*Boys will receive less instructional time than girls.

4 Weeks $1,650 (Boys $1,250*)

3 Weeks $1,350 (Boys $1050*)

2 Weeks $1,150 (Boys $850*)

1 Week $750 (Boys $550*)

Please indicate which weeks you will be attending: *

To be considered eligible for the performance on 7/19, students must attend week 7/15 and at least one additional week.

Week of 6/24

Week of 7/1 (no classes 7/4)

Week of 7/8

Week of 7/15

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19 *

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. First State Ballet Theatre has put in place preventive measures to reduce the spread of COVID-19; however, First State Ballet Theatre cannot guarantee that you or your child(ren) will not become infected with COVID-19 and First State Ballet Theatre cannot prevent you or your child(ren) from becoming exposed to, contracting, or spreading COVID-19 while attending class at First State Ballet. Furthermore, attending class at First State Ballet Theatre could increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending First State Ballet Theatre and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I acknowledge that it is not possible to prevent against the presence of the disease. Therefore, if you or your children choose to attend classes at First State Ballet or enter into the Facility you may be exposing yourself to and/or increasing your risk of contracting or spreading COVID-19. I understand that the risk of becoming exposed to or infected by COVID-19 at First State Ballet Theatre may result from the actions, omissions or negligent of myself and others, including, but not limited to, First State Ballet Theatre employees, volunteers and program participants and their families. I agree that I am personally responsible for my safety and actions while attending classes at the First State Ballet Theatre. I agree to comply with all policies and rules for class instruction, including but not limited to all CDC policies, guidelines, signage, and instructions. Because multiple people will be attending classes from different households, I recognize that I and my children are at higher risk of contracting COVID-19. With full awareness and appreciation of the risks involved, I, for myself and on behalf of my family, spouse, estate, heirs, executors, administrators, assigns, and personal representatives, hereby forever release, waive, discharge, and covenant not to sue The First State Ballet Theatre and/or any member of the First State Ballet Theatre staff, employees, officers and directors (collectively the “Released Parties”) from any and all liability, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, or injury, including death, that may be sustained by me or my children related to COVID-19 whether caused by the negligence of the Released Parties, any third-party at the classes, or otherwise, while participating in any activity while in, on, or around the theatre or class instruction and/or while using any portion of the Facility. I represent, warrant, and agree to the following:

I understand the symptoms of COVID-19 as described by the World Health Organization including but not limited to fever, shortness of breath, dry cough, fatigue, body/muscle aches or lack of taste or smell.

I affirm that neither I, my minor student, nor any member of my household, currently has or has experienced the aforementioned symptoms within the past 14 days. Furthermore, I will immediately inform First State Ballet Theatre and discontinue classes if I, my minor student, or any member of my household, develops any of the aforementioned symptoms.

I affirm that neither I, my minor student, nor any member of my household, has been diagnosed with COVID-19 within the past 30 days. Furthermore, I will immediately inform First State Ballet Theatre and discontinue classes if I, my minor student, or any member of my household, is diagnosed with COVID-19.

I affirm that neither I, my minor student, nor any member of my household, has knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days. Furthermore, I will immediately inform First State Ballet Theatre and discontinue classes if I, my minor student, or any member of my household, is knowingly exposed to anyone diagnosed with COVID-19.

I affirm that neither I, my minor student, nor any member of my household, has traveled outside of the country or to any city considered to be a "hot spot" for COVID-19 infections within the past 30 days. Furthermore, I will immediately inform First State Ballet Theatre and discontinue classes once I, my minor student, or any member of my household, returns from traveling outside of the country or to any city considered to be a "hot spot" for COVID-19 infections.

I understand that First State Ballet Theatre cannot be held liable for any exposure to the COVID-19 virus caused by any misinformation on this form or the health history provided by each Student.

I have read and understood all procedures put in place by First State Ballet Theatre to prevent the spread of COVID-19.

I HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THIS RELEASE, AND FREELY AND KNOWINGLY ASSUME THE RISK AND WAIVE MY RIGHTS CONCERNING LIABILITY AS DESCRIBED ABOVE.

FSBT Summer Intensive Registration Terms and Conditions *

Payment Conditions In signing this registration form for myself or on behalf of a minor student, I have read and understand the payment schedule set forth below. In order to secure a place in the Summer Intensive Program, a $100.00 non-refundable deposit must accompany registration. This deposit will be applied to the total tuition. TUITION IS NON-REFUNDABLE, with the exception of medical disability, with documentation from a doctor. NO REFUNDS OR CREDITS WILL BE GIVEN FOR CLASSES MISSED. In signing this registration form for myself or on behalf of my minor student, I understand that the balance of the Summer Intensive Program tuition is due on June 1, 2024 and that a $15.00 late fee will be applied to the tuition after this date. Liability Release I agree that my minor student or that I myself will abide by the polices of The School of First State Ballet Theatre. I consent to my minor student or myself participating in the school’s programs and activities. I recognize that in spite of the care of the school and its teachers that there is a possibility of injury during classes. In the case of such an injury to myself or my minor student, I release The School of First State Ballet Theatre, its teachers and associated personnel from all responsibility. Medical Release In the event of an injury to myself or my minor student which requires emergency medical attention, I permit the school to obtain such care and I promise to pay all associated costs upon receipt of the bill. Publicity Release I hereby authorize The School of First State Ballet Theatre the use all photographs and video of my minor student or myself for publicity including advertising and sales promotion. I have read, understand and agree to the policies of The School of First State Ballet Theatre, Payment Conditions, Liability Release, Medical Release and the Publicity Release.

I accept the above Terms and Conditions