2017 Summer Ballet Intensive Paper Registration by The Rock School for Dance Education

THE ROCK SCHOOL FOR DANCE EDUCATION | SUMMER BALLET INTENSIVE REGISTRATION | 2017

STUDENT INFORMATION First Name

Last Name

Home Address

City

State

Zip/Postal Code

Birth Date

Age

Gender

Country

Home Phone

Student Email

2016-2017 School Grade

Student Email

Student Cell Phone (if available)

Audition Date

Audition Site

Accepted Level

Scholarship (if applicable)

PARENT/GUARDIAN INFORMATION Mother’s Name

Cell Phone

Work Phone

Father’s Name

Cell Phone

Work Phone

BILLING ADDRESS - IF DIFFERENT FROM STUDENTS Person responsible for payment

First Name

Last Name

Billing Address City

State

Zip/Postal Code

Day time phone

Evening Phone

Country

STUDENT’S T-SHIRT SIZE All Summer Ballet Intensive students receive an exclusive Summer 2017 T-shirt! Shirts are limited to one per student. Select student’s size below: Youth XS

Youth XS

Ladies XS Men XS

HOW DID YOU HEAR ABOUT US? I am a returning summer student I am a current school year student I was referred by my dance teacher I was referred by a past summer student I was referred by a current / former school year student I saw an article or advertisement in ___________________________ (name of publication/website) Facebook YAGP USAIBC Twitter Tumblr Other_______________

THE ROCK SCHOOL FOR DANCE EDUCATION | SUMMER BALLET INTENSIVE REGISTRATION | 2017

2017 SUMMER BALLET INTENSIVE SESSION SELECTION Please fill in the session(s) requested. Registrations will not be processed for students attempting to register for incorrect levels. Ballet level placements and scholarship offers are given following an audition. The front office will contact you if any session chosen is no longer available at the time of registration. Wait lists are available.

LEVELS 2-2X $585 ........................ 1 WEEK $1,080 ................... 2 WEEKS $1,500 ................... 3 WEEKS $1,995 ................... 4 WEEKS $2,370 ................... 5 WEEKS $2,865 ................... 6 WEEKS

LEVELS 3-6 (July 31 - August 4) (June 26 - July 7) (July 10 - July 28) (July 10 - August 4) (June 26 - July 28) (June 26 - August 4)

SESSION Example: 2 Week Session

$585 ............................... 1 WEEK $1,155 ........................... 2 WEEKS $1,620 ........................... 3 WEEKS $2,115 ........................... 4 WEEKS $2,610 ........................... 5 WEEKS $3,105 ........................... 6 WEEKS BALLET LEVEL

(July 31 - August 4) (June 26 - July 7 (July 10 - July 28 (July 10 - August 4) (June 26 - July 28) (June 26 - August 4) TUITION Full session amount

$ Ballet Tuition Scholarship (if applicable)

( ______%)

Total DANCE Tuition Due: $ _________________________

HOUSING / ROOM & BOARD $690 ........................ 1 WEEK $1,368 ................... 2 WEEKS $2,016 ................... 3 WEEKS $2,706 ................... 4 WEEKS $3,210 ................... 5 WEEKS $3,900 ................... 6 WEEKS

(June 27 - July 8) (July 11 - July 29) (June 27 - July 29) (August 1 â&#x20AC;&#x201C; August 5) (June 26 - July 28) (June 26 - August 4)

MOVE-IN & MOVE-OUT DATES Move-In date: 1 day before session Move-Out date: 1 day before session Airport transportation is available for students traveling as unaccompanied minors. See website for pricing and details.

Limited housing is available during the one-week session. When moved from Level 2X to 3 a student will be billed the difference in price, adjusted to accurately reflect number of Saturday classes student will attend. HOUSING TUITION Full session amount

HOUSING SESSION Example: 2 Week Session

$ Housing Scholarship (if applicable)

( ______%)

Total HOUSING Tuition Due: $ _________________________

THE ROCK SCHOOL FOR DANCE EDUCATION | SUMMER BALLET INTENSIVE REGISTRATION | 2017

ROCK ACADEMICS SUMMER OFFERINGS Students may check all that apply. SAT/PSAT Prep Rock Academics is offering the Official Princeton Review SAT Fundamentals Course during the 5 Week Summer Intensive Program. Three days a week for five weeks, students will receive 15 hours of live instruction that will help them master the content covered in the new SAT. Students will gain an understanding of the different question types and learn test-taking strategies. Classes will be held in the morning prior to dance class. Spaces limited, class subject to enrollment. Open to students in Levels 3XPM, 4, 5, and 6. Tuition:

$700

Sum m er Session High School Credit Students who wish to earn additional high school credit can enroll to Keystone during the Rock School Summer Intensive. The Rock Academics Summer Session runs through the five week and students can enroll in one course. Classes will be held in the morning prior to dance class. The Director of Rock Academics will remain available to the student throughout the program to answer questions and to otherwise support the student through his/her course work. Families must supply their own laptop for the Summer Session. Open to students in Levels 3X-PM, 4, 5, and 6. Check therockschool.org for a list of approved Summer courses. Tuition:

$500 for half credit course $750 for full credit course

Sum m er Session Academ ic Support Students who are currently enrolled in an outside high school program and wish to utilize the Rock Academics classroom and support during the Summer Intensive can do so by enrolling in the Rock Academics Summer Session Support. The classroom will be open in the morning prior to dance class. The Director of Rock Academics will remain available to the student and his/her family during the Intensive to answer questions and to otherwise support the student through his/her course work. Families must supply their own laptop for the Summer Session Support. Open to students in Levels 3X-PM, 4, 5, and 6. Tuition:

$100 for Two Week Session $150 for Three Week Session $250 for Five Week Session

For questions, please contact our Director of Academics, Robert Hodges at academ ics@ therockschool.org Total ACADEM ICS tuition due: $__________________

THE ROCK SCHOOL FOR DANCE EDUCATION | SUMMER BALLET INTENSIVE REGISTRATION | 2017

PAYMENT OPTIONS - Select either Pay in Full or Three Installments Pay in Full (due at time of registration)

$ $ $ $65 (+$50) $

DANCE Total Due: HOUSING Total Due: ACADEMICS Total Due: Registration Fee: Scholarship Fee (if applicable):

PAYMENT AMOUNT:

Pay in Three Installments (1ST installment due at time of registration) DANCE Total Due: HOUSING Total Due: ACADEMICS Total Due: Registration Fee: Scholarship Fee (if applicable): st

1 PAYMENT AMOUNT (Installment + Fees):

$ $ $ $65 (+$50) $

INSTALLMENT PAYMENT SCHEDULE 1ST Installment + Registration Fee March 15, 2017 2nd Installment April 15, 2017 3rd Installment May 15, 2017

METHOD OF PAYMENT - For Full amount or 1st Installments $____________ CHECK or money order payable to the Rock School

$__________ CASH paid to The Rock School through the front office $__________ CREDIT CARD payment: American Express Account Number:

Visa

Master Card

OPTION FOR AUTOMATIC CREDIT CARD PAYMENTS (three installment payment plan only)

I authorize The Rock School to automatically charge my credit card on the second and third installment dates listed above.

Discover

______________________________________

Expiration Date: ____________________CW#: _______________ Name as it appears on card:________________________________

Please be aware that it is your responsibility to update The Rock School on any credit card changes. You may opt in or out of AutoPay at any time by contacting The School. Auto-Pay is for DANCE and HOUSING Tuition only. All other fees must be authorized separately.

Signature of Cardholder: __________________________________ Please note: this authorizes one charge only. Your credit card will not be automatically charged for remaining installments unless you select the Auto-Pay option in the upper right corner.

Special Early Pricing Pay full ballet tuition amount below two weeks after audition (for master-class auditions) or two weeks from acceptance notification (for in-class auditions or video). You may still pay room & board in three installments Contact The School for details

THE ROCK SCHOOL FOR DANCE EDUCATION | SUMMER BALLET INTENSIVE REGISTRATION | 2017

RELEASE OF CLAIMS & MEDICAL AUTHORIZATION FORM PLEASE COMPLETE AND RETURN TO THE SCHOOL BY EMAIL, MAIL, OR FAX | ATTN: 2017 SUMMER 1101 South Broad Street | Philadelphia, PA 19147 | (Fax) 215-551-8538 | medical@therockschool.org Medical Form Statement of Privacy - The Rock School takes great care in protecting medical information of all students. Student medical forms are securely stored at The School and are only made available to authorized staff members on a need to know basis. Medical forms are made available to medical authorities in case of emergency and students’ medical information will be shared with medical authorities, as deemed appropriate. All medical forms for the 2017 summer session will be shredded and destroyed upon the close of the session. The School will not retain any obsolete student medical information or files. ALL INFORMATION MUST BE CLEARLY PRINTED OR TYPED. FORM MUST BE COMPLETED IN ITS ENTIRETY AND SUBMITTED NO LATER THAN JUNE 21, 2017.

STUDENT INFORMATION Student’s Name: ________________________________________________ Class/Level: _______________________ Date of Birth: _________________________________________

Gender: __________________________

Home Address: ___________________________________________________________________________________ City: __________________________________ State:

____________________ Zip: ___________________________

Allergies: ___________________________________ Other Medical Conditions: _______________________________ Session/# of Weeks: __________________________ Resident or Commuter: __________________________________

EMERGENCY INFORMATION Primary Contact (Parent/Guardian)

Secondary Contact (Parent/Guardian)

Name

Home Phone:

Work Phone:

Cell Phone:

E-mail:

We will always contact parents/guardians first. Please list additional emergency contacts below: Full Name:

Home Phone:

Work Phone:

Full Name:

Home Phone:

Work Phone:

INSURANCE INFORMATION PLEASE COPY BOTH SIDES OF YOUR MEDICAL INSURANCE CARD ONTO A PAGE AND ATTACH TO THIS COMPLETED FORM

Name of Insurance Carrier

Telephone Number:

Address of Insurance Carrier Policy Identification Number:

Group Number:

Subscriber’s Full Name:

Relation to Student:

Physician’s reports/immunization records are not needed for Summer sessions.

PARENT/GUARDIAN’S APPROVAL AND MEDICAL RELEASE I personally, as the participating student or the parent or guardian of such student, intending to be legally bound, do hereby, for myself, my heirs, executors, and administrators, waive and release The Rock School for Dance Education, their officers, representative, successor, and/or assigns for any and all damages which may be sustained or suffered by the student in connection with association with the above program, or any activities related thereto, including without limitation, traveling to or participating in and returning from any activity associated with the program. The named student has received a physical examination by a physician and has been found physically capable of participating in any activity associated with the program.

I hereby give authorization to The Rock School to share any and all medical information and/or medical documents to treating medical authorities. It is understood that The Rock School will make every effort to contact me prior to the emergency treatment of my student, but that treatment by a licensed physician or medical staff person of a licensed emergency room will not be withheld if I cannot be reached.

____________________________________________ Signature of Parent/Guardian

____________________________________________ Date

This form is required for all Rock School students. Students who do not complete this form will not be allowed to participate in dance classes.

THE ROCK SCHOOL FOR DANCE EDUCATION | SUMMER BALLET INTENSIVE REGISTRATION | 2017

The Rock School | Care Waiver for 2017 Summer AGREEMENT made between ___________________________, The Parent(s)/Guardian(s) of ______________ (Student) and The Rock School. WHEREAS, the Parent(s)/Guardian(s), in their absence, desire to convey upon The Rock School and its employees the rights and responsibilities of care of their child/ward and The Rock School and its employees wish to assume those rights and responsibilities. NOW, THEREFORE, the parties hereto mutually agree as follows: 1. CARE The Rock School employees shall have the following powers with regards to the above named student: a. To seek medical care for the student, including but not limited to visits to the doctor and/or hospital, as needed, at the discretion of the Rock School and its employees. b. To authorize medical treatment or medical procedures in the event of an emergency, as needed at the discretion of the Rock School and its employees. c. To administer over the counter medications, as needed in the discretion of the Rock School and its employees, as directed on the package, for the following medications: Ibuprofen Midol

Benadryl Tylenol

Pepto Bismol Aspirin

Tums Other __________________

If your child has a history of frequently needing over the counter medications or requires a medication not listed above, please supply your own medication. For all over the counter medication provided to The Rock School by Parent(s)/Guardian(s), the medication must be in the original sealed container labeled with your child’s first and last name. All medications supplied to The Rock School will be kept in a locked cabinet and used only for your child. I give my student permission to self-administer over the counter medication(s) as directed on the package, in the original container labeled with my child’s first and last name. My student needs to have over the counter medication(s) administered by a Rock School employee. d. Regarding prescription medications: I give my student permission to self-administer prescription medication(s).. My student needs to have prescription medication(s) administered by a Rock School employee. As the parent/guardian, I will provide written permission in the form of a letter, email or fax that will list: a. Reason for taking this medication b. Time/Routine of administration c. Physician comments about the medication d. Full name of student e. Name of medication f. Medication dosage The medication must be in a prescription container with a pharmacy label on the bottle. Label must contain the child’s name, name of medication, dosage, interval, date of prescription and prescribing physician. All medications supplied to The Rock School will be kept in a locked cabinet and used only for your child. 2. TERM The period of care shall be the duration of the 2017 Summer session. If the student withdraws or is dismissed prior to the end of the Summer, the period of care shall extend only until such time as the student is no longer enrolled at The Rock School. 3. GOVERNING LAW The Agreement shall be construed in accordance with the laws of the State of Pennsylvania. 4. GENERAL This Agreement contains the entire agreement of the parties relating to the subject matter here of. Only an instrument in writing signed by both parties hereto may modify this Agreement. ____________________________________________ Parent/Guardian (print your name here) Date

____________________________________________ Parent/Guardian (sign your name here) Date

THE ROCK SCHOOL FOR DANCE EDUCATION | SUMMER BALLET INTENSIVE REGISTRATION | 2017

PHOTO, VIDEO, AUDIO, AND INTERVIEW RELEASE Unless otherwise noted, as the parent or legal guardian of the student named, my signature below grants permission for my child or ward to be photographed, videotaped, and/or interviewed during the course of the Summer Ballet Intensive by The Rock School or any of its authorized agents, and consent for the publication, broadcast, or other use of the student's images and/or words for the purposes of promoting The Rock School. In addition, I, intending to be legally bound for myself, my heirs, executors, and administrators, release The Rock School, or any parties acting on their behalf and with their approval, from liability for such uses of my child's or ward's images and/or words. ____________________________________________ Parent/Guardian (print your name here) Date

____________________________________________ Parent/Guardian (sign your name here) Date

HOUSING WAIVERS & POLICY AGREEMENT PARENT/GUARDIAN OF A COMMUTING STUDENT DOES NOT NEED TO SIGN BELOW

BUS TRANSPORTATION WAIVER I hereby give permission for my child to travel to and from any/all destinations for the duration of The Rock School’s 2017 Summer Ballet Intensive. I understand that the driver, vehicle owner, The Rock School for Dance Education and its employees are not responsible for any injury/ damages which may be incurred on said trip, and in consideration for providing transportation, I agree to hold The Rock School for Dance Education and its staff, as well as the drivers and owners of the vehicles transporting the student, harmless from claims for injury or damages occurring during said trip. SWIMMING POOL & GROUNDS WAIVER (Cabrini College only) This Agreement waives the liability of The Rock School for Dance Education and its employees for any use of the services and facilities at Cabrini College, included but not limited to the swimming pool and grounds. I hereby agree that the use of the services and facilities at Cabrini College, included but not limited to the swimming pool and grounds, is at my and my child’s own risk. As a condition of my child’s use of such services and facilities at Cabrini College, included but not limited to the swimming pool and grounds, I, on behalf of my child (and my child’s heirs and assigns) expressly agree to forever discharge, waive, and release the The Rock School for Dance Education, its directors, management, staff, servants, agents, employees, and/or independent contractors and their heirs, successors, and assigns from any and all claims, demands, injuries, liabilities, actions, causes of action and from all acts of active or passive negligence on the part of the The Rock School for Dance Education and its Directors, management, staff, servants, agents, employees, and/or independent contractors and their heirs, successors and assigns on account of any and all injuries or damages, including but not limited to bodily injury, mental injury, and/or property damage from any event, mishap, accident, loss, damage, or injury suffered by myself or my child resulting from or connected with or caused by the use of the services and facilities at Cabrini College, included but not limited to the swimming pool and grounds. I further agree to defend, indemnify, and hold harmless the The Rock School for Dance Education and its Directors, management, staff, servants, agents, employees, and/or independent contractors and their heirs, successors, and assigns from any and all claims, losses, and liabilities arising from, connected to, and/or arising from my and/or my child’s use of the services and facilities at Cabrini College, included but not limited to the swimming pool and grounds. I declare and affirm that my child is in good medical and physical condition, and use of the services and facilities at Cabrini College does not pose any danger to my child’s health. I further agree to abide by the rules and regulations of Cabrini College and The Rock School for Dance Education as they now exist or may be amended in the discretion of The Rock School for Dance Education. HOUSING POLICIES & PROCEDURES AGREEMENT By signing below, you formally accept the Busing & Swimming Pool & Grounds Waivers (as written above) in addition to the HOUSING POLICIES & PROCEDURES, available at the front office window and/or at therockschool.org/summer/summer-at-rock-center/policies-procedures

____________________________________________ Parent/Guardian (print your name here) Date

____________________________________________

Parent/Guardian (sign your name here) Date

THE ROCK SCHOOL FOR DANCE EDUCATION | SUMMER BALLET INTENSIVE REGISTRATION | 2017

STATEMENT OF RESPONSIBILITY Students attending The Rock School during the 2017 Summer Ballet Intensive are expected to behave in a disciplined, responsible, and courteous manner. Persons unwilling or (due to pre-existing injury or chronic illness) unable to fully commit themselves to the daily regimens, to maintain work habits appropriate for a serious student, or to conform to reasonable and accepted standards of discipline are advised not to enroll in The Rock School 2017 Summer Ballet Intensive. Students must be developmentally and physically capable of participating in all classes without assistance. The Rock School for Dance Education is a non-smoking facility. The Rock School reserves the right to immediately dismiss any student from the 2017 Summer Ballet Intensive whose attitude, class attendance, work habits, interrelations with fellow students, school faculty & staff, or overall behavior is in violation of: • The Rock School’s BALLET INTENSIVE POLICIES & PROCEDURES, available at the front office window and/or on The Rock School website, therockschool.org/summer • The rules governing The Rock School’s showcases/performances. • The policies and procedures governing payment and scholarships (if applicable). • Conduct judged as unacceptable by The Rock School, including behavior that is considered undisciplined, irresponsible, discourteous, dishonest, harmful, or otherwise unacceptable. • Local, state, and/or federal laws. By signing below, you formally accept the BALLET INTENSIVE POLICIES & PROCEDURES, available at the front office window and/or at therockschool.org/summer/summer-at-rock-center/policies-procedures.

____________________________________________ Parent/Guardian (print your name here)

____________________________________________ Date Parent/Guardian (sign your name here) Date