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SWAN BALLET DANCE SCHOOLS

swanballetdanceschools.com

FAIRFAX SWAN 1 CHANTILLY SWAN 2

9416 Main Street 13655-B Lee Jackson Hwy

Fairfax, VA 22031 Chantilly, VA 20151

(703) 425-9400/425-7847 (703) 803-8877

swanballetdance @aol.com chantillyswanballet@verizon.net

REGISTRATION/HEALTH CONSENT FORM

Please read thoroughly and understand that by signing this form, you are agreeing to comply with all the information contained


A $30.00 non-refundable registration fee is required from each new student entering the school. All students who have withdrawn with written notice will be required to pay a $25.00 returning student fee. Again, these fees are non-refundable.

Tuition fees are to be paid by the 10th of each month. After the 10th, there will be a $20.00 late fee charged. The fall/spring schedule runs from September to the end of June; the summer schedule runs for the months of July and August. The schedule of classes will have minor changes three times a year: September, January and July. Please be sure to pick up new information to insure that you remain informed. To avoid the late fee, you may pay for any of our seasonal rates. There is a $20.00 handling fee for any returned checks. We only accept cash or checks for payments. NO CREDIT/DEBIT CARDS. Tuition payments are the same amount monthly or seasonally regardless of the number of times a class meets during that month. Holidays are covered by a 5th day in some months or by a make-up class. Money will not be refunded for missed classes, nor will discounted tuition rates be permitted to carry over make-up classes into another season. The school should be notified in advance when a student will miss class. Missed classes must be made up within 4 weeks of the missed class. Students should not arrive more than 10 minutes prior to the class starting time, and should be promptly picked up no more than 10 minutes after class ends. After every 10 minutes, a $5.00 fee will be charged. Exceptions may be made in cases of emergency and/or if prior arrangements have been made with the instructor.

Swan Ballet runs on a full year schedule. Students are enrolled year to year unless they officially withdraw by giving 30 days advance notice in writing, Plus that months tuition. This includes withdrawing for the summer. Students who do not give notice will be billed for any preceding lessons plus one month.

Please follow them accordingly. No chewing gum, food, or drink is allowed in the studio itself, only in the reception area. It is the student’s responsibility to make sure that they clean up after themselves.

All students must wear the appropriate dance attire to classes. For ballet and tap: pink or black leotard, pink tights, pink ballet slippers and hard soled shoes or tap shoes for tap. For jazz: any color leotard and tights (nothing bare midriff, please), ballet slippers or black oxfords for jazz. Jewelry should not be worn in class. Hair must be pulled up in a bun and away from the face and neck for all classes. Swan Ballet is very strict with the dress and hair codes.

Parents are permitted to observe classes the 2nd class meeting in October and February ONLY. Should fewer than three students attend a class, the class will be held for 30 minutes and the students who attend will be invited to make up the class at a later date. Any concerns, suggestions, or complaints should be discussed privately with management. Please note: Swan Ballet is offering special rates and discounts on tri-annual (4 months), bi-annual (6 months), and annual (12 months) tuition payments. We encourage all of our students to take advantage of these amazing rates.

I have read and fully understand the rules and regulations listed above and do hereby agree to abide by these rules.

PARENTS/GUARDIANSIGNATURE:____________________________________________________DATE:______________

I, the above signed parent or guardian of________________________________, applicant, hereby agree to save and indemnify and keep harmless the said Swan Ballet Dance Schools, its agents and sponsors against any and all liability, claims, judgments or demands for damages arising as a result of injuries sustained by the applicant during, or as a result of any course of instruction given the applicant by Swan Ballet Dance Schools. Or any medical problems arising out of pre-existing conditions including but not limited to diabetes, asthma, food or environmental allergies/reaction to, physical plant, etc.

PLEASE PRINT CLEARLY

STUDENT’S FULL NAME:_____________________________________________ D.O.B.: ____________ AGE _______

PARENTS’ Name: Mother:__________________________­­­­­­___ Father:______________________________________

STREET ADDRESS:________________________________________________CITY:____________________________

ZIP CODE:___________ PHONE(HOME):________________­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­__________________

PHONE Mother: (WORK): ______________________ (CELL):___________________________

Father: (WORK): ______________________ (CELL):__________________________

Email Address: ____________________________________________

How did you hear about how did you hear about us? ________________________________

Health Release Record: Is student named above in good health? ( ) yes ( ) no

Is student taking any medications? ( ) yes ( ) no If Yes, please List: __________________________

Are there any physical or emotional handicaps or problems that the school should be aware of? ( ) yes ( ) no

If yes, please explain ___________________________________List any allergies: _________________________

Emergency Contact: Name: _______________________________Phone #:_________________________

THIS INFORMATION WILL BE KEPT CONFIDENTIAL

Payment: Date__________/Check #___________/Amount___________

Day & Time of Class:________________________________________

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Lilie Kianpour,
Aug 29, 2014, 8:44 AM
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