Summer Workshop with Artists of American Midwest Ballet


Student's Name: _________________________________________________________________

Gender:  ____  Female                ____ Male

Date of Birth:  _________________________  Age (as of 6/10/19):  _______

Address:  _______________________________________________________________________

Mother's Name: __________________________ Father's Name: __________________________

Parent's Cell Phone #: _____________________________________________________________

Parent's Email Address: ____________________________________________________________

Please indicate your participation:    ____  Full 2 Week Program
                                                          ____  1 Week (June 10-14)
                                                          ____  1 Week (June 17-21)
                                                          ____  Single Days or Single Classes (please list dates below)

This Application must be accompanied by the $25 Application Fee by check or money order payable to Motion41
Dance in order to be processed.  This amount will applied to your tuition total (Application fee will not be applied
to the overall total for those participating by the single class.)  Application Fees are non-refundable.

50% of your tuition total is due on or before May 1, 2019.
All Tuition balances must be paid by June 7, 2019.
 Dancers with an open balance will not be permitted to take class.
Tuition is completely non-refundable for any reason.
Any student applying after May 31st will be charged the following:
         - An additional $100 for 1 Week or 2 Week participants
         - An additional $50 for Single Day participants
         - An additional $25 for Single Class participants

By Signing below, you acknowledge that you understand and agree to the policies stated in this application.  You also release
Motion41 Dance or any of its instructors (guest teachers or otherwise) from any and all liability in the event that the student
becomes injured or ill while participating in the Summer Workshop or any of its related activities.

  Signature (must be parent or guardian if the student is under the age of 18)