Student Last Name:
Student First Name:
Level Placement :
Age as of June 16, 2024: Date of Birth(MM/DD/YY):
Gender:
I am registering for:
Pre-Ballet 3/4/5: Students age 3, 4, & 5
Primary: Students age 6 & 7
Student Contact Information
(Please write N/A if student does not have cell phone or e-mail address)
Address:
City: State: Zip:
Home Phone: Cell Phone:
Student's E-mail Address:
Parent/Guardian #1 Contact Information
Relationship (mother, step-father, etc.):
Name (First and Last):
Address:
City: State: Zip:
Home Phone:() Cell Phone:()
Home E-mail Address:
Work Phone:() Ext:
Parent/Guardian #2 Contact Information
Relationship (mother, step-father, etc.):
Name (First and Last):
Address:
City: State: Zip:
Home Phone:() Cell Phone:()
Home E-mail Address:
Work Phone:() Ext:
Person(s) to contact in an emergency if Parent/Guardian #1 and #2 are unavailable.
Name (First and Last): Relationship (grandmother, family friend, etc.):
Home Phone:() Cell Phone:() Work Phone:()- Ext:
Name (First and Last): Relationship (uncle, teacher, etc.):
Home Phone:() Cell Phone:() Work Phone:()- Ext:
Additional Information
If you would like to include additional child/family information, please attach a note. Examples of helpful information might include custodial arrangements, restraining orders, family circumstances affecting attendance or tardiness, etc.
Medical Release
This information is to help the OBT School/OBT, and their authorized agents seek medical attention for your student should you be unavailable in the event of an injury or emergency. We will make every effort to contact you, or a designated alternate, in the event of an emergency. This form provides our staff with the authorization necessary to treat or seek treatment for your student should an accident occur at the OBT School/OBT studios or performance venues. Furthermore, this authorization will be used in the event that emergency or hospital care becomes necessary.
Parent/Guardian Authorization:
The student herein described has permission to engage in all prescribed activities, except as noted by me, either individually or on the advice of a physician. The student’s history is correct and complete to the best of my knowledge.
I hereby grant permission to OBT School’s/OBT’s company physician and physical therapy staff (or in the event of emergency room care, the attending physician and/or ER staff) to order x-rays, routine tests, and/or treatment for the health of my student. In the event I cannot be reached in an emergency, I hereby grant permission to the physician selected by OBT School/OBT to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my student, as named above.
Medical Contact Information
Student’s Physician: Phone: ()
Student’s Dentist/Orthodontist: Phone: ()
Medical Insurance Company*:
*If student does not have medical insurance, write N/A.
Address: Phone: ()-
Group #: Responsible Party:
Hospital of Choice**:
**This choice may not be accommodated due to the nature/severity of the injury or due to time restraints with respect to receiving immediate care.
Medical History
List medications currently taken*:
*If student does not take any medications, write N/A.
List allergies (to medication, foods, etc.)*:
*If student does not have any allergies, write N/A.
Does the student have any medical condition, illness, or injury of which we should be aware, i.e., allergies, ADD/ADHD diagnosis, any orthopedic injury, chronic illness, medication use on site, etc.*:
*If student does not have any medical conditions, illnesses, or injuries, write N/A.
Permission to Give Over-the-Counter Medication
Please check which of the following over the counter medications we may give your child without your additional permission?
Pediatric Motrin Pediatric Tylenol Pediatric Aspirin
Adult Ibuprofen Adult Tylenol Adult Aspirin
Child’s Weight (for dosage purposes only):pounds
Authorization to Pick-up & Permission to Leave Premises
Person(s) who may pick-up student:
Person(s) who may not pick-up student:
My child has permission to leave OBT School/OBT’s studios, unchaperoned, for lunch (OBT School does not provide a cafeteria facility or lunch program):
Yes No
My child has permission to leave OBT School/OBT’s studios, unescorted, after class:
Yes (complete information below) No (preferred option for students under 12)
Will the student be in possession of a cell phone?
No Yes Student’s cell phone number: ()-
Will the student use public transportation after class?
No Yes Bus/Route Number Bus Stop ID/Location
Will the student walk home after class:
No Yes Direction walking from OBT School/OBT
Parents may update this form at any time. Please notify the school in writing if there are any permanent or temporary changes to the above information.
Parent's/Guardian's Initials: Date:
(Required if student is under 18 years of age)
Disclosure
Please read carefully through the following disclosures. Your signature verifies your agreement to the terms required of all registered students.
In signing this registration form, I, the student, and we, the parent(s)/guardian(s), acknowledge our commitment, including financial, to fulfill the entirety of our registered session. Oregon Ballet Theatre School reserves the right to terminate a student’s enrollment if they are unable to participate in accord with OBT School’s expectations of timely payment of tuition, attendance, or conduct.
OBT School refunds 100 percent of tuition fees for classes, workshops, masterclasses, and other fee-based instruction, canceled due to low enrollment. In the event of circumstances beyond its reasonable control, including acts of God, earthquakes, fires, floods, inclement weather, civil disturbances, epidemics, and riots OBT School will do its best, if possible, to offer make up class options. Make up class schedules are at the sole discretion of OBT School and may not accommodate each student’s specific scheduling requirements. In the event OBT is not able to offer make up classes, the organization will consider all refund requests, though approval of a refund shall be at the discretion of OBT. Refunds exclude, but do not solely exclude, registration, finance, NSF, and audition fees.
OBT School and Oregon Ballet Theatre (OBT) shall have the absolute sole and perpetual right and permission to use, publish and/or reproduce in any form or any manner, photograph, film, videotape, audiotape, digital recording, or any other form of representations in which the publicity during the term of this Agreement shall be under OBT School’s/OBT’s sole control, and the student shall cooperate by engaging in such publicity and activities as may be directed by OBT School/OBT. The student shall not communicate with the media except under coordination with and approval of OBT School/OBT.
It is agreed that I, my child, adopted or otherwise, and my heir and executors, waive and release all rights and claims for damages that I may have at any time against OBT School/OBT, its representatives whether paid or volunteer, for any injury or damages in connection with OBT School's curriculum or other activities related to OBT School/OBT. The risks involved with respect to such a program are fully understood. I authorize OBT School/OBT and its employees or agents to provide or secure emergency medical treatment for me or my child on my behalf if deemed necessary.
I have read, understood, and agree to all the terms that are set forth as requirements on this registration form. I realize that it is my responsibility to familiarize myself with OBT School’s policies and expectations, through the printed and published materials made available to me. This release is valid for the registered session listed on this form.
Parent's/Guardian's Initials: Date:
(Required if student is under 18 years of age)