2010 MAB Summer Camp - Registration
A deposit of $50 per week is due by April 1 with registration.
A refund or credit will only be issued in the event of a medical disability verified by a physician.
Payment in full for camp is due by 6/1/10.
Please return registration with payment to: Mid-Atlantic Ballet, P.O. Box 161, Newark, DE 19715
Please Print
Student’s Name______________________________________________Age_____D/O/B___________
Address___________________________________________City/State/Zip_______________________
Phone #_____________________________E-mail__________________________________________
Mother’s Name_______________________ Phone #__________________Cell #__________________
Father’s Name ________________________Phone #_________________Cell #__________________
Emergency Contact___________________________________ Relation to student_________________
Phone #__________________________________Cell #______________________________________
Please list any/all current/chronic injuries, medical conditions, and allergies preventing your child from
participating in any strenuous physical indoor/outdoor activities:
Are you a new student at MAB? _______ If yes, please complete the following:
How did you hear about MAB? __________________________________________________________
Please place a check by all applicable spaces
I would like to register for: Ballet Camp _____ July 5 - 9
Tuition Due: __$235
Total Tuition ______ Check enclosed___ Cash enclosed ____
T-Shirt Size ____Child Small ____Child Medium ____Child Large
Waiver and Release:
I understand that Mid-Atlantic Ballet may from time to time take photographs and/or videotapes of the student enrolled
on this form and I authorize the Mid-Atlantic Ballet to use these photographs and videotapes for archival and publicity purposes.
Recognizing the risks of illness and injury inherent in any dance program, I am participating upon the express
agreement and understand that I am hereby waiving and releasing Mid-Atlantic Ballet, it’s employees and board of directors
from any and all claims, costs, liabilities expenses or judgments, including attorney’s fees and court costs arising out of my
participation in Mid-Atlantic Ballet’s programs or any illness or injury resulting there from, and thereby agree to indemnify and
hold harmless Mid-Atlantic Ballet, it’s employees, and board of directors from and against any and all claims except for illness or
injury resulting from gross negligence or willful misconduct on the part of Mid-Atlantic Ballet. I hereby execute and deliver the
Waiver and Release to induce Mid-Atlantic Ballet to permit me/my child to participate in its programs. I hereby grant the staff
and /or board of directors permission to administer first aid help and/or call 911 in case of medical emergency while I am/my
child is attending classes, rehearsals, and performances or events on or off-site. I understand that Mid-Atlantic Ballet will
attempt to first notify parents and guardians in case of emergency.
I understand that the art of dance and nature of dance instruction may sometimes require a teacher to touch me/my
child. I also understand that this will happen, in a caring, gently and appropriate manner.
Signature ______________________________________Date_____________________
(Parent or legal guardian if student is under 18 years of age)