AMHERST BALLET

29 Strong Street

Amherst, MA 01002

413-549-1555

www.amherstballet.org

info@amherstballet.org

2007-2008 ADULT BALLET REGISTRATION FORM

Dancer Name__________________________________ Date__________________

Address____________________________________________________________

Phone________________________Cell Phone_____________________________

Work Phone____________________ E-Mail Address________________________

Dance Experience ____________________________________________________

Any medical problems/concerns? ___________________________________________________________________

_______________________________________________________________________________

Adult/Teen Beginning Ballet

[ ] Monday 7:00 – 8:30 September 10 – December 17. 13 wks @ $169

No classes 10/8 or 11/12

[ ] Monday 7:00 – 8:30 January 7 – 28. 3 wks @ $39

No class 1/21

[ ] Monday 7:00 – 8:30 February 4 – May 12. 13 wks @ $169

No classes 2/18 or 4/21

Adult Intermediate/Advanced Ballet

[ ] Thursday 7:00 – 8:30 September 13 - December 13. 13 wks @ $169

No class 11/22

[ ] Thursday 7:00 – 8:30 January 3 – 24. 4 wks @ $52

[ ] Thursday 7:00 – 8:30 January 31 – May 15. 13 wks @ $169

No classes 2/21, 3/13 or 4/24

[ ] Thursday 7:00 – 8:30 May 22 - June 12. 4 wks @ $52

To the best of my knowledge I am in excellent health and can fully and safely participate in classes at Amherst Ballet (AB). I will not hold AB or AB Theatre Co., their employees or board members liable for any injury that may incur in class, rehearsal or on the premises. If necessary, I have included medical information indicating prior injury or condition that may effect my participation in class/rehearsal activities.

Signature Date

PAYMENT PLAN (please check choice of payment)

[ ] 1 payment due on the first day of class in September 2007

[ ] 1 payment due the first day of class in January 2008

[ ] 1 payment due the first day of class in February 2008

[ ] 1 payment due the first day of class in May 2008

[ ] 1 payment each month due on the first. Add $10 administrative fee.

[ ] I prefer to buy a Class Card. Check option below.

[ ] 10 Class Card @ $135. Expiration date 1/31/08

[ ] 5 Class Card @ $70. Expiration date 1/31/08

[ ] 10 Class Card @ $135. Expiration date 6/12/08

[ ] 5 Class Card @ $70. Expiration date 6/12/08

1 Class @ $14

--office use only--

DUE	$ RCVD	DATE	CHECK #	INV #
Admin. Fee
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2.
3.
4.
5.
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7.
8.
9.

Please note that you are responsible for the total amount due unless you notify Amherst Ballet that you have dropped a class or withdrawn from the school.