Adaptive Dance Registration Spring 2019 Adaptive Dance Registration FormStudent Name First Last Student AgeStudent Birth Date Please indicate which session you are registering your student for: 1:45 - 2:30 p.m. / grades 1-6 2:45 - 3:30 p.m. / grades 7 - 12 Academic school student will attend in the 2018 - 19 academic year.Grade student will be in during 2018 - 19 academic year.Student Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent / Guardian Name First Last Parent / Guardian Email Address Enter Email Confirm Email Parent / Guardian Cell PhoneAccommodations / additional information you would like to share:What other activities does your child participate in, both in and out of school? (i.e. music lessons, sports, etc.)Family Physician Name / Phone:Allergies / Medical Conditions / InstructionsEmergency Contact Name / Phone:Release and Waiver of LiabilityPlease read and check Yes or No below.I recognize the risks of accident or injuries associated with any program of dance and acknowledge that I am participating upon the express understanding that I am willing and able to accept full responsibility for my own safety and welfare. I hereby release PBT/PBT School and agree to hold PBT/PBT School harmless from and against any and all claims and liabilities whatsoever which I may have, arising out of the participation with PBT/PBT School, except for those relating from gross negligence or willful misconduct of PBT/PBT School. I hereby execute and deliver this release to induce PBT School to permit me to participate in its programs. In teaching the art of ballet, it is appropriate for a teacher to put their hands on a student to correct the student’s posture, physical line or positioning of the student’s body, or to help a student hold a position. PBT School does not tolerate harmful or inappropriate teacher-student. By participating in PBT School activities and programs, parents acknowledge that it is PBT School practice to correct students with physical contact. Additionally, by signing below on behalf of my child, I assume the risk associated with dance instruction/classes and agree that the PBT School, PBT and its Board of Trustees, faculty and volunteers shall not be liable in any way for any injuries sustained or loss of property while attending PBT School or any of its related functions. Release and Waiver of Liability - Yes Release and Waiver of Liability - No Media ReleasePlease read check Yes or No below. I do hereby give, grant and assign to Pittsburgh Ballet Theatre, Inc., and its assigns, licensees and legal representatives (“PBT”) the right, consent and permission to use, publish, copy, reproduce, create digitized images of, adapt, distribute, transmit, broadcast, display, modify and otherwise make use of my (or my minor child, as appropriate) appearance, likeness and form in all forms of media and in all manner now known or hereafter to become known, including electronic media and/or composite representations, for advertising, trade, or any other lawful purpose. PBT shall have the right to exercise such rights with my appearance, likeness and form alone, or with other materials, including, but not limited to, text, data, images, photographs, illustrations, animation, graphics, and video or audio segments of any nature. The rights granted to PBT hereunder are world-wide, irrevocable, perpetual, and assignable. I hereby waive all rights and release PBT and its directors, officers, employees, agents, and independent contractors from, and shall neither sue nor bring any proceeding against any such parties for, any liability, loss, demands, claims, damages or causes of action, whether now known or unknown, for defamation, invasion of right to privacy, publicity or personality or any similar matter, or based upon or relating to the use and exploitation of my appearance, likeness and form. Media Release - Yes Media Release - No Additional InformationUse of Contact InformationBy completing this form, I grant PBT permission to use my personal information to contact me about upcoming events and promotions. PBT will not rent, sell, or share personal information with third-party companies or organizations unless permission is received. Yes No Please let us know how you heard about the class:EmailThis field is for validation purposes and should be left unchanged.