NESA Ballet Registration

Parent/Guardian #1 Information
Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number

Area CodePhone Number
Email
example@example.com
Occupation
Employer
Do you wish to add information for a second parent/guardian?

Parent/Guardian #2 Information
Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number

Area CodePhone Number
Email
example@example.com
Occupation
Employer

Alternate Pickup/Release

Please share the name and contact information of the individual(s) in addition to parents/guardians permitted to pick up your child.
Individual #1

First NameLast Name
Phone Number

Area CodePhone Number
Relation to child
Individual #2

First NameLast Name
Phone Number

Area CodePhone Number
Relation to child
Individual #3

First NameLast Name
Phone Number

Area CodePhone Number
Relation to child

Medical Release Information

Please share your medical and health insurance information in case of emergency.
Health Insurance Provider
Health Insurance Policy Number
Primary Physician
Physician Address
Physician Phone Number

Area CodePhone Number
Hospital Preference
Please list any allergies:
Please list any medical conditions, injuries, or physical limitations:
Please list any learning, sensory, access, or support needs:

Liability Release and Assumption of Risk

I give permission for the above-named student/myself to participate in classes, rehearsals, performances, and related activities offered by New England School of the Arts and NESA Ballet. I understand that dance and movement activities involve inherent risks, including but not limited to slips, falls, muscle strains, sprains, collisions, and other injuries. I understand that NESA Ballet will take reasonable precautions to support participant safety, but that risks cannot be eliminated entirely. To the fullest extent permitted by law, I release and hold harmless New England School of the Arts, NESA Ballet, its directors, employees, teachers, volunteers, agents, and representatives from any and all claims arising from participation, except where prohibited by law.
Medical Authorization

I understand that I am responsible for providing medical insurance coverage and for notifying NESA Ballet of any medical condition, injury, allergy, medication, or support need that may affect participation. If I cannot be reached in an emergency, I authorize NESA Ballet staff or representatives to seek emergency medical care for the participant named above. I understand that I am responsible for costs associated with such care or treatment.
Terms and Conditions

1. Enrollment, placement, and schedule changes are subject to class capacity, appropriate placement, and NESA Ballet policies. 2. Tuition payments, refunds, withdrawals, missed classes, make-up classes, and credits are governed by the written policies provided by NESA Ballet. 3. Families/participants agree to communicate medical, attendance, payment, or schedule concerns promptly and in writing. 4.NESA Ballet may adjust classes, schedules, instructors, or placement when necessary to support student safety, educational quality, or sufficient enrollment. 5. Participants and families agree to follow NESA Ballet expectations for respectful behavior, attendance, attire, safety, and care for the learning environment.
Media / Publicity Permission
Parent/Guardian Name

First NameLast Name
Student/Participant Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Thank You!

Thank you for completing registration for NESA Ballet. You will receive an email confirming your registration shortly. Please email jenniferchambers@nesarts.org with any questions.
Full tuition is due one week before the start of class. For those who register after that deadline, online payment is required at the time of registration.

Cancellations: It may be necessary for a parent to cancel a student's registration after full tuition has been paid. If cancellation is due to a serious illness or injury that prevents participation in camp activities, New England School of the Arts will refund the paid tuition minus the deposit provided that a doctor’s note certifying the illness or injury is submitted in writing. Any cancellations for other reasons are not subject to refunds.

Waitlists: Once we reach capacity for a class, we will start a waitlist. To sign up for the waitlist, fill in an application online. There is no deposit required to be placed on the waitlist.
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NESA Ballet Registration

Parent/Guardian #1 Information

Parent/Guardian #2 Information

Alternate Pickup/Release

Medical Release Information

Liability Release and Assumption of Risk

Medical Authorization

Terms and Conditions

Payment Information

NESA Ballet Payment

Thank You!