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__________________
Other____________________ Other_________________
Family Physician_____________________________________ Phone___________________________
Any known medical problems, allergies or medications being taken that we should know about in case of
emergency___________________________________________________________________________________
____________________________________________________________________________________________
___________________________________________________________________________________________
Classes Enrolling In:
I Plan to participate in the Spring Recital or workshop performance: yes______ no____
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 overed 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, to use
pbhographs/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_____________
Please mail completed registration form, along with May's tuition and $35 registration fee, or $250 registration fee for
Study Abroad Workshops to:
Grebel Dance, 102 Commerce Parkway, Pelham, Al 35124 or, pay online using PayPal here:
Princesses & Princes Study Abroad Registration $250
Junior Camp Intensive Study Abroad Tuition $500
Summer Intensive I & II Study Abroad Room/Board $500*
(*subject to additional fees)
Grebel Dance Yearly Family Registration $35
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