Registration Form

Registration Form For Open Classes

Date
Name
Address
Home Phone		Cell or Other
Email Address
Date of Birth
Place of Employment		Work Phone

Does your company have a matching gift program? Yes No

Emergency Contact		Phone Number
Physician		Phone Number

	Medical conditions, allergies or special needs:

	Previous ballet training (optional):

	Special skills and interests:

	Referred to Western Ballet by:


Would you be interested in helping in Western Ballet's productions? Yes No

	READ WAIVER All students must read the waiver before submitting an application. By submitting this form (Clicking on SUBMIT) you are stating that you have read and are in agreement with the waiver.