Mail to: 112 Fountain Street, Mineral Point, WI 53565-1308
SABA Student Registration Form
Name ________________________________________________________ Birthdate ___________________
Parents __________________________________________________________________________________
Home Phone ________________________________ Cell Phone _________________________________
Address _________________________________________________________________________________
_______________________________________________________________ ZIP _____________________
e-Mail ___________________________________________________________
If no e-mail access, is there a phone number where a message can be left after 11 p.m.? ________________________________________
Class(es) in which to be enrolled: Day(s) and Time(s)
1 ________________________________________________________________________________________
2 ________________________________________________________________________________________
3 ________________________________________________________________________________________
Prior Experience ___________________________________________________________________________
_________________________________________________________________________________________
Any prior or current injuries that may hinder training? ______________________________________________
_________________________________________________________________________________________
How did you hear of SABA? ____ friend/relative ____ phone book _____ internet search
____ public appearance at _____________________________________________________________
____ newspaper ad in ________________________________________________________________
____ OTHER _______________________________________________________________________
WAIVER: The undersigned has read and understands the policies of the Academy. S/He is aware of and accepts the risks inherent in the training of ballet/dance. S/He hereby agrees to hold Summer Hamille and the Southwest Academy of Ballet Arts, Inc. harmless from any and all liability, loss, damage, costs or expenses that arise from the student's participation in this activity. It is also understood that occasional physical touching is necessary to assist the student in grasping the concepts of this training.
___________________________________________________________________ __________________
Parent/Guardian or Adult Student Signature Date 