Student:______________________________________Birthdate___________

Address:_________________________________________________________

City:_______________State:_________Zip:_________

Phone:__________________

Parent / Guardian:______________________________________________

Medical Conditions (if applicable)_________________________________

_________________________________________________________________

Class: ______________________ Tuition: $__________

Tuition

Reg. Fee / Insurance fee *

Pre-registration discount
($10 discount on full payment only available if tuition and fees are paid in full before August 22)

TOTAL:

Payment option: Full Payment: $________
or
Three (3) installments of: $_________

  $______

+$ 30.00

-$______



  $______

I hereby release the Cache Valley School of Ballet, it's officers and employees from any liability or expense (including attorney's fees) with respect to claims for injuries, damages and expenses sustained by above enrolled student resulting from participation in ballet classes.

Parent / Guardian Signature:________________________________________ Date:__________________

Complete this form, sign, and return with tuition, registration / insurance fees. Please fill out a separate form for each student enrolling in classes. Make check payable to CVSB and mail to:

 Cache Valley Civic Ballet
 Attn: Registrar
 P.O. Box 3775
 Logan, UT 84323-3775

* If paying in three installments, the first payment plus registration / insurance fees should be included with registration form.