Participation Registration Form

Please read through the following information and fill out all information below:

DANCER INFORMATION

Dancer 1

Dance/Movement Information: Please list the classes you are registered for this fall:
Special Programs: Please list special programs/intensives participated in over the summer:
Please enter known medical conditions, including food / drug allergies. Also, any medications taken regularly:

Dancer 2 (Skip this section if you only have one dancer applying)

Dance/Movement Information: Please list the classes you are registered for this fall:
Special Programs: Please list special programs/intensives participated in over the summer:
Please enter known medical conditions, including food / drug allergies. Also, any medications taken regularly:

Dancer 3 (Skip this section if you only have one dancer applying)

Dance/Movement Information: Please list the classes you are registered for this fall:
Special Programs: Please list special programs/intensives participated in over the summer:
Please enter known medical conditions, including food / drug allergies. Also, any medications taken regularly:
Performance Availability (check one):
Rehearsal Availability: Will you be available to rehearse Columbus Day weekend? (October 12-14):

Participation Fees

Participation fee: The participation fee (below) will need to be brought to the first rehearsal the dancer is attending. Please make checks payable to NCBE. If financial aid is needed, please contact pncbe@yahoo.com for availability and requirements.

Participation with NCBE: ages 5-9: $100; ages 10-12: $200; ages 13 and older: $300
Absence Notification Procedure
Emergency Contact: This information is to be used in case parent / guardian is not present during rehearsal or performance. Contact attempts will begin with parent / guardian, then onto emergency contact and physician if necessary.

Talent Release

I grant North Country Ballet Ensemble (NCBE) and its designees the right to use my name, likeness, image, voice, appearance, and performance as embodied in their marketing efforts whether recorded on or transferred to video files, film, slides, photographs, audio tapes, or other media, now known or later developed. This grant includes without limitation the right to edit, mix, or duplicate and to use or re-use in these efforts in whole or part as they may elect. NCBEor its designee shall have complete ownership of the interest or ownership in the Product orits copyright.

I also grant NCBE and its designees the right to broadcast, exhibit, market, sell, andotherwise distribute these materials, either in whole or in parts, and either alone or with otherproducts, for commercial or non-commercial television or theater, closed-circuit exhibition,home video distribution, or any other purpose that NCBE or its designees in their solediscretion may determine. This grant includes the right to use the media for promoting orpublicizing any of the uses.

! confirm that I have the right to enter into this agreement, that I am not restricted by anycommitments to their parties, and that NCBE has no financial commitment or obligations tome as a result of this agreement. I hereby give all clearances, copyright, and otherwise, foruse of my name, likeness, image, voice, appearance, and performance embodied in thematerials. I expressly release and indemnify NCBE and its officers, employees, agents, anddesignees from any and all claims known and unknown arising out of or in any wayconnected with the above granted uses and representations. The rights granted NCBEherein are perpetual and worldwide.
I have read the foregoing and understand its terms and stipulations and agree to all of them:

Background Check Disclosure Agreement

Background Disclosure: For the safety of all the children performing with NCBE, all adults must clear the NYS Sexual Abuse Registry. I authorize the use of this information for a background check. By checking this box you agree to these terms:

I release and hold harmless all parties involved from any and all liability for damages arising from requesting, procuring or furnishing the requested information except with respect to a violation of the Act. I authorize the employer and its agent/credit reporting agency and all associated entities and its clients to receive any criminal history information or credit report pertaining to me in the files of any state or local criminal justice agency.

Please read the following carefully before signing this application:
I certify that I have and will provide information that is correct and complete to the best of my knowledge. I understand that information contained on this form will be verified by NCBE. I understand that misrepresentations or omissions may be cause for my immediate rejection to participate with NCBE or my termination as a volunteer.

Thank you for registering for the Nutcracker!

Pay My Participation Fee online

If you choose to pay by check:

REMINDER: The Participation Fee (see below) is due at the first rehearsal the dancer is attending. Please make checks payable to NCBE. If financial aid is needed, please contact pncbe@yahoo.com for availability and requirements.
WHEN SELECTED, Participation FEES ARE:
Ages 5-9: $100
Ages 10-12: $200
Ages 13 and older: $300
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Photos by Lisa Keegan, Keegan Photography Design