Ballet Adventures - The Nutcracker Ballet Adventures RegistrationThe Nutcracker Ballet Adventures class is on Saturday, Dec. 15 from 11:30 am - 12:20 pm at the Benedum Center. Please use this form if you have already purchased tickets for the 2 PM performance of The Nutcracker on Dec. 15. If more than one student will be participating please complete separate forms for each. Date Student Name First Last Student AgeParent / Guardian Name (must remain with student during class) First Last Parent / Guardian Email Address Enter Email Confirm Email Parent / Guardian Cell PhoneParent/Guardian 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 Release and Waiver of LiabilityPlease review and indicate agreement below.By signing below on behalf of my child, I assume the risk associated with dance instruction/classes and agree that the Pittsburgh Ballet Theatre and its Education Department (PBT) and their respective Board of Directors, faculty, staff, teaching artists and volunteers shall not be liable in any way for any injuries sustained or loss of property while attending a dance class or any related functions. In the event that I am not present at the class, I hereby grant permission to instructional staff 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 alternate family representative cannot be contacted. In the art of ballet and other dance forms, a teacher may put their hands on a student to correct the student’s posture, the physical line, position of the student’s body or part of his/her body, or to help a student hold a position. PBT doesn’t tolerate any inappropriate or harmful teacher-student contact. By participating in PBT activities and programs, I acknowledge that PBT teachers/instructors may correct students with physical contact. Release and Waiver of Liability - Agree Media ReleasePlease read check Yes or No below.MEDIA RELEASE: 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 SignatureYour signature below indicates acceptance of all terms and conditions included here. This constitutes the entire agreement between PBT and the undersigned. Please type parent or guardian name in the box below to indicate signature.PaymentBallet Adventures Registration Price: $18.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name NameThis field is for validation purposes and should be left unchanged.