Leatherstocking Ballet, Inc.

The Leatherstocking Ballet holds its classes at the Midtown Utica Community Center (MUCC) 
43 Scott Street Utica, NY

Upcoming Events

​Performaces TBD

Acro for dancers
Acrobatic Arts certified syllabus.

Progressing Ballet Technique certified instructor.
Registration forms are available in electronic format by emailing leatherstockingballet@gmail.com and may be filled in and returned electronically. (Sample forms included below)

You may also request forms by mail by calling the School office at (315) 737-0703.

Registration forms must include the registration fee to hold a spot in the class. 
Contact Information


Address:_______________________________________________City:___________________ State:______   Zip Code:_________

Home Phone:______________________________Cell Phone_________________________________:

Date of Birth:_____/______/____   Age:_________________________ E-Mail Address:___________________________________

Emergency Contact Name:____________________________________________  Phone:______________________________

Relationship to Dancer:_______________________________________________________

Dance History
Type of Dance _________________________________Studio Name ______________________________

___Ballet Technique   ____Pre-Pointe / Pointe     ___Jazz    ____Lyrical     _____Hip Hop       ____Tap     _____Other:

Medical History

Please answer the following questions as carefully and accurately as possible. This form is for use only in the event of a medical emergency. Information provided will be kept strictly confidential.
                                                                                                                                                                                        Yes                No
Do you have Asthma?
Do you have any heart problems that require you to take any medications or that involve any restrictions?
Do you have Diabetes?
Are you allergic to any medications?    (If yes, please list:)
Do you have any other allergies such as: pollen, bee stings, etc.?   (If yes, please list:)
Has anyone ever told you that you have an eating disorder?
Do you wear glasses or contacts?
Do you have any problems with joints or muscles?

List of hospital admissions, including operations, serious illnesses (including Chicken Pox) and severe injuries. 
Please date:

Explain any item's that were checked “yes” above:

Height: __________________________   Weight: ________________________

Please give dates:
(Hepatitis) _______________
FLU ____________________

___Please check here if you are attaching a copy of Immunizations

Picture Consent and Waiver Form
Web Page / Electronic Media / Newspapers / Brochures

Date________________________________         Dancer’s Name _________________________________________________

I hereby consent to having 's picture appear in electronic media or print publications that The Leatherstocking Ballet, Inc. might choose to release. I understand that his/her picture may be on display in accordance with any of the above mentioned activities. I further acknowledge that my child's name may or may not be used in connection with his/her picture. I hereby agree on behalf of the above named dancer and with agreements of his/her parent or legal guardian to waive any claims against The Leatherstocking Ballet, Inc. which may arise from the use of any pictures used in accordance with any Leatherstocking Ballet publications. If at any time, I want my child's photograph(s) to be removed from the Leatherstocking Ballet's web site or other electronic media, I acknowledge that it is my responsibility to inform, in writing, to the Board of directors.

**This waiver also includes any outside events that help promote Leatherstocking Ballet.**

Parent’s/Guardian’s Signature____________________________________________________________________

Medical Release Form

Dancer’s Name:________________________________________________     Date of Birth:_____/_____/____   Sex: M  or F
                              (Last Name)               (First Name)                  (M.I.)                                    (Mo)    (day)   (Yr)        (Circle One)

Father's Name (or guardian):________________________________Mother's Name (or guardian):______________________________

Home mailing address:________________________________________________________________________________________
                                        (Street # OR P.O Box,                                    Town or City,                     State,                  Zip Code)

Home Phone:_______________________ Father's Work# _______________________Mother's Work#:_________________________

Medical Insurance Provider:______________________________________________Subscriber I.D. #:__________________________

Physician's Name:_____________________________________________________Physician’s Phone Number: __________________

Preferred Hospital:________________________________________________

Please read and sign:

In case of an emergency, I consent for emergency room physician or nearby provider to perform any treatment deemed necessary.

Signature of Custodial Parent or Legal Guardian______________________________________    Date:_______________________

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