2009 REGISTRATION FORM
Francia Russell Center Summer Dance Workshops July 6 – August 21 Please mail registration form by June 1, 2009 to: Pacific Northwest Ballet School, The Francia Russell Center 13440 NE 16th Street, Bellevue, WA 98005 Phone: 425.451.1241, Fax 425.468.1742
Student’s Name Parent’s Name Address City/State/Zip Home Phone Birthdate Emergency Contact Info Name Mother’s Work Phone Age Phone
□ Male
□ Female
E-mail
Father’s Work Phone Level Relationship to Student
Movement Pre4- MondayCreative Movement / Pre-Ballet, Ages 4-7, Monday-Friday
(Students may register for more than one session) Cost: $220 per session; Morning Session Times: 9:00-11:30 a.m., Afternoon Session Times: 12:30-3:00 p.m. Each daily session includes a one-hour dance class, one hour of arts and crafts and a snack break.
Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7
Cinderella Swan Lake A Midsummer Night’s Dream Nutcracker Cinderella Sleeping Beauty Coppélia
July 6-July 10 July 13-July 17 July 20-July 24 July 27-July 31 August 3-August 7 August 10-August 14 August 17-August 21
□ morning □ morning □ morning □ morning □ morning □ morning □ morning
□ afternoon □ afternoon □ afternoon □ afternoon □ afternoon □ afternoon □ afternoon
All sessions subject to cancellation, pending enrollment.
Please call for confirmation. All class times subject to change. A non-refundable $50 tuition deposit per session is due with your registration form and will be credited toward tuition. Tuition must be paid in full by June 1, 2009. There is a $20 charge for returned checks. No refunds will be made after June 1, 2009.
□ Enclosed is my check or money order made payable to: Pacific Northwest Ballet School
Tuition □ Tuition in Full Please charge my account: □ American Express Card Number
□ $50 Non-Refundable Deposit (per session) □ Discover
Expiration Date
□ MasterCard
□ Visa
Signature/Date
Agreement: 1. I agree that I will not hold the Pacific Northwest Ballet Association, or any faculty member or employee, liable for injuries sustained or illnesses contracted by my daughter/son while a student at Pacific Northwest Ballet School. 2. I give my permission for Pacific Northwest Ballet School to take photos of my daughter/son to use for purposes of promoting the School.
Signature of Parent or Guardian