<p> Print Student Name: ______Level Assigned:______Annual registration fee of Thirty ($30) dollars per student paid on (date): ______Check #______CC#______circle : Visa or Mastercard San Name on CC______Exp.______CVC#:______Billing Address:______City: ______Die Zip: ______Home Address: ______City: ______Zip: ______Email: ______Alt. Email: go ______Current Age: ______DOB: ______Academic School: ______Grade: ___ Sch Parent/Guardians - Name:______Name:______Primary Contact – Name: ______Cell Phone: ool ______Secondary Contact – Name: ______Cell Phone:______of Student’s Home Phone #: ______Student’s Cell Phone#:______Parent/Guardian’s Employers: Bal ______In Case of Emergency please notify: Name/Relation: ______Phone: let ______S Former training at: ______Location: ______T REGIS Year instruction commenced: ______Amount of weekly U TRATI classes/hrs:______D ON Amount of classes per week: ______Reason for transfer: ______E FORM How did you hear about us? N 2015/ ______Have you T 2016 attended any of San Diego Ballet’s professional performances? ______Has there been a history of medical problems? No_____ Yes_____ If so, and they could be relevant to the instruction of the student, please indicate:______Please list Approving to this condition includes incidents experienced within the building and, or any asthma outside the Dance Place San Diego building, as well as at off site theaters, schools or other or allergies: locations. ______I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE POLICIES & LIABILITY RELEASE ______Signature: ______Date______************ ************ Printed Name: ______Relation to Participant: ______************ ************ 2650 Truxtun Road, Suite 102 · San Diego, CA 92106 · fax: 619.294-7315 ph: 619.294-7374 email: [email protected] ************ ************ ************* ******LEGAL CLAUSE RELEASING LIABILITY – If student is a minor this waiver MUST be signed by their legal guardian.</p><p>I understand that neither the San Diego School of Ballet, Inc., San Diego Ballet, Dance Place San Diego, the Owner, the Director, the Instructor(s) nor any of their employees or volunteers, will be held responsible or liable for any injury, accident, or damages that may occur on these premises. </p>