Community Youth Scholarship Audition Registration Form Community Youth Scholarship Audition Registration FormToday's Date Student Name First Last Student Birth DateStudent Age(Student must be between the ages of 5 and 8 years old as of Sept. 1, 2019.)School student will attend in the 2019 - 20 academic year.Grade student will be in during the 2019 - 20 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 If the student lives in the city of Pittsburgh, please let us know which neighborhood.Student Race / Ethnicity / Origin. Please check all that apply (Optional). American Indian or Alaska Native Asian Black or African American Hispanic, Latinx, or Spanish Middle Eastern / North African Native Hawaiian or Pacific Islander White / Caucasian Some other Race, Ethnicity or Origin GenderParent / Guardian Name First Last Parent / Guardian Email Address Enter Email Confirm Email Parent / Guardian Cell PhonePlease list any dance experience your child has had (no dance experience is necessary).What other activities does your child participate in, both in and out of school? (i.e. music lessons, sports, etc.)Is your child able to participate in all classes at PBT School during the upcoming school year?* Yes, my child is able to participate fully. No, my child cannot participate fully. If no, please explain:Family Physician Name / Phone:Allergies / Medical Conditions / Instructions:Emergency Contact Name / Phone:Financial EligibilityPlease read and submit financial documentation.For your child to be eligible for the scholarship, your family must meet the income level eligibility for free and reduced-price meals through the National Lunch Program. You can find the income guidelines for 2019 at this web address (please cut and paste into your internet browser): https://www.govinfo.gov/content/pkg/FR-2019-03-20/pdf/2019-05183.pdf. The annual income level you must not exceed is found in the column titled "Reduced Price Meals: Annual." Please check below which document you will provide to confirm your eligibility. If possible, please upload your document using the File Upload tab below. Please be sure to black out private information such as social security numbers. Or you may mail or email your document to Kathryn Gigler, Director of Education, Pittsburgh Ballet Theatre, 2900 Liberty Ave., Pittsburgh, PA 15201; firstname.lastname@example.org. Please submit your documentation PRIOR to the audition. Free and Reduced Lunch eligibility letter from your child's school. (Does not apply to PPS; please select another form of documentation.) Copy of the first 2 pages of your 2018 federal tax return. Current unemployment eligibility documentation. SNAP benefits eligibility documentation. File Upload Drop files here or Accepted file types: jpg, pdf, png, gif. Medical and Media ReleaseMedical Release: Please read and check Yes or No below.*By checking "yes" below on behalf of my child, I assume the risk associated with dance instruction / classes and agree that the Pittsburgh Ballet Theatre School (PBTS), Pittsburgh Ballet Theatre (PBT), and its Board of Directors, Faculty, Staff and Volunteers shall not be liable in any way for any injuries sustained or loss of property while attending PBTS or any of its related functions. I hereby grant permission to the Director and /or staff of PBTS to authorize hospital admission and medical, surgical, and emergency treatment, including blood or blood product, transfusions, and diagnostic procedures. Additionally, I grant permission for the administration of anesthesia for the student where medically necessary in case of emergency, accident, and illness, and only in the case that the parent or Family Physician, listed above, cannot be contacted. Yes, I have read, understand and affirm the Medical Release statement. No, I do not affirm the Medical Release statement. Media Release: Please read and 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 (or my minor child, as appropriate) 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 (or my minor child, as appropriate) appearance, likeness and form. Yes, I have read, understand and affirm the Media Release statement. No, I do not affirm the Media Release statement. Attendance, Expectations, and NotificationAudition Attendance and Enrollment Expectations: Please read and indicate your response below.Attendance at the audition does not constitute an immediate scholarship. If awarded, the scholarship will be good for the entire 2019 - 2020 school year and is subject to renewal by an end-of-year review with PBTS personnel, the student and family. Students who receive a PBTS scholarship are held to the highest of standards. Students and their families agree to: (1) attend every regularly scheduled class (no unexcused absences); (2) arrive and be picked up on time (transportation is not provided); (3) buy proper ballet attire to wear during class (approximately $100/year in the Children's Division); (4) be prepared to participate fully in class; (5) abide by the safety, respect and etiquette rules of PBTS. I have read, understand, and agree to the scholarship attendance rules and expectations. Notification: Please read and indicate your response below.Scholarship recipients will be notified within 2 weeks of the audition. Recipients will then have 2 weeks to complete the necessary paperwork to accept the scholarship. Should a scholarship recipient decline their scholarship or not complete their paperwork within the 2 week time period, every effort will be made to contact other qualified students from the audition to take their place. I have read and understand the scholarship notification process. Other Community Arts OpportunitiesIf your child is NOT selected for a scholarship, would you like to receive information about other arts opportunities through PBT, including notifications of next year's scholarship audition? Yes No Please let us know how you heard about the scholarship audition:PhoneThis field is for validation purposes and should be left unchanged.