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The School of
Dance
Audition
Number______
Studio School Application Form
Semester-2004 Contact Information: Name: _____________ Birth date: _________ Age: _______ Last Name: _________ First Name: _________ Middle Initial: ____ School Grade/Year: ________ Gender: F M Parent/Guardian: (If under 18) Address: ________________ Relationship to dancer: _____________ City State Zip: ______________ Employer(s): ______________ Day phone: ____________ Evening phone: _________ Cell phone: ___________ Email: __________ Dance Background: Ballet: Years studied: Where/with whom: Jazz/Modern: Years studied: Where/with whom: Other: ____________ Years studied: Where/with whom: Medical Information: Last Name: ___________ First Name: __________ Middle Initial: _____ Your answers to the following questions will help us provide valuable information to our funders: In what ward does the dancer live? (Circle one) 1 2 3 4 Don’t Know 5 6 7 8 MD resident VA resident What is dancer’s ethnic background (circle all that apply) Asian Black Hispanic Pacific Islander White Other How did you hear about The School of Dance? (Circle all that apply) Flyer/poster Word of mouth City Paper S of D Teacher S of D Student Radio Television Other (Please specify) What is your annual household income? (circle one) Up to $25,000 $50,000 to $99,999 $150,000 and above $25,000 to $49,999 $100,000 to $149,999 Waiver I/We guarantee that all of the above information is true. I/We give permission for the aforementioned student to participate in dance classes, auditions, and/or performances hosted by the School of Dance (S of D). I/We will allow any photographs or other such images of the student to be used by S of D in any publications or advertisements now or in the future. If any medical emergency should arise while the student is in the care of S of D staff, then I/We give permission for the student to be taken to the hospital to receive any needed medical attention. I/We also hereby release and hold harmless S of D, its respective trustees, officers, employees, agents and independent contractors from and against any and all liability, damages, costs and expenses (including but not limited to reasonable attorney and paralegal fees), obligations, claims, penalties and charges with respect to any events or matters arising out of, or directly or indirectly resulting from (including, but not limited to bodily or mental injury) the aforementioned student’s participation in any activity sponsored by and/or related to S of D. Signature(s) Dancer’s Signature ___________________ Parent/Guardian Signature (If Dancer is under 18) __________________ Dancer’s Social Security Number _______________ Parent/Guardian’s Social Security Number _______________ Date __________ |
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