The Leatherstocking Ballet holds its classes at the Midtown Utica Community Center (MUCC)
43 Scott Street Utica, NY
Twas the Night Before Nutcracker
Acro for dancers
Acrobatic Arts certified syllabus.
Progressing Ballet Technique certified instructor.
Address:_______________________________________________City:___________________ State:______ Zip Code:_________
Home Phone:______________________________Cell Phone_________________________________:
Date of Birth:_____/______/____ Age:_________________________ E-Mail Address:___________________________________
Emergency Contact Name:____________________________________________ Phone:______________________________
Relationship to Dancer:_______________________________________________________
Type of Dance _________________________________Studio Name ______________________________
___Ballet Technique ____Pre-Pointe / Pointe ___Jazz ____Lyrical _____Hip Hop ____Tap _____Other:
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.
Explain any item's that were checked “yes” above:
Height: __________________________ Weight: ________________________
Please give dates:
___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.**
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: __________________
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:_______________________