RegistrationForm

The Stevan Grebel Center for Dance and
Grebel Ballet Workshops Registration Form
Fill out and print this form and send in with your check or pay using Pay Pal

Name of Student or
participant______________________________________________________________________

Address_________________________________City_______________St___________Zip___________

Birthdate___/___/___ Academic School__________________Grade__________School Phone__________

Parents or Guardian's Name_____________________________________________________________

Address_________________________________City______________St___________Zip____________

Home Phone______________   Email______________________________________________________

Father's Phone                                Mother's Phone
Home____________________        Home_________________

Work_____________________       Work_________________

Cell______________________        Cell__________________

Family Physician_____________________________________ Phone___________________________

Any known medical problems, allergies or medications being taken that we should know about in case of
emergency___________________________________________________________________________________

Classes Enrolling In:

Years of Training at Grebel Dance _____________________________
Previous Dance Training:

Release and Waiver of Liability and Indemnity Agreement:

Release/authorization made on_______________________by(parent/guardian)___________________________

of(student)_____________________________________________.
In consideration of being permitted to participate in any way in the Dance Program and/or being permitted to enter for
any purpose any restricted area (here in defined as any area where in admittance to the general public is prohibited),
the parent(s) and/or legal guardian(s) of the minor participant named below agree:

I/We fully understand an acknowledge that there are risks and dangers associated with participation in dance events
which could result in physical injury. I/We accept and assume such risks and responsibility for the losses and/or
damages following such injury, and agree that The Stevan Grebel Center for Dance shall not be liable in any way for
injuries sustained during attendance at The Stevan Grebel Center for Dance or any of its related functions.

I/We grant my(our) child, or ward, permission to participate in The Stevan Grebel Center for Dance program. I/We
HEREBY RELEASE,WAIVE, DISCHARGE AND COVENANT NOT TO SUE The Stevan Grebel Center for Dance,
including its owners, managers, promoters, lessees of premises used to conduct the dance event or program, premises
and event inspectors, underwriters, consultants and others who give recommendations, directions, or instructions to
engage in risk evaluation or loss control activities regarding the dance facility or events held at such facility and each of
them, their directors, officers, agents, employees, all for the purposes herein referred to as "Releasee"...

Further, I grant The Stevan Grebel Center for Dance, its agents and employees, permission to authorize any emergency
medical treatment that may be required for my child, or ward, during the school session. I/We are covered by our own
family insurance policies, as this is the only form of reimbursement.

Medical Insurance Company___________________________________Policy Number______________________

As a representative of The Stevan Grebel Center for Dance, I agree to abide by the rules and regulations of the dance
school.

Signature of Student___________________________________________ Date_____________________________

I/WE HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT,
FULLY UNDERSTAND ITS TERMS, HAVE SIGNED IT FREELY AND VOLUNTARILY WITH THE FULL KNOWLEDGE OF
ITS SIGNIFICANCE.

Signature of Student___________________________________________ Date_____________________________

Signature of Parent/Guardian if student is a minor__________________________________Date____________

Photo Release Form
I hereby give permission for The Stevan Grebel Center for Dance and the official photographer, Igor N. Rykov, and
Grebel Dance to use phographs/videos of my child, or likeness thereof, in The Stevan Grebel Center for Dance and
Alabama Youth Ballet school and program sponsored publications and for promotional purposes.

Signature of Student_________________________________________ Date______________________________

Signature of Parent/Guardian if student is a minor_______________________________ Date_____________

Suggeested Dress Code:
Ladies - any color leotard, pink or black tights, pink or white ballet shoes. Hair must be
secured off face and in a bun or twist.
Men - white t-shirt, black tights, black or white shoes.
No Jewelry except small earrings, please.

Grebel Dance: 102 Commerce Parkway, Pelham, Al 35124     Phone: 205-987-7234     Email: info@grebeldance.com

Class Title	Day of Class	Time of Class

School/Teacher	Classes	Years of Training	Classes per Week