Early Registration Deadline: March 1, 2014 = $585 tuition
Regular Registration Deadline: April 10, 2014 = $625 tuition
Email completed registration form to [email protected]Or print and mail to:
Ann Cooper Albright Warner Center 30 N. Professor St. Oberlin, OH 44074
Please keep a copy for your records.
APPLICANT INFORMATION
Full Name __________________________
Date of Birth _______________ Age as of July 6, 2014 ________ Email __________________________________
* Please add [email protected] to your email contacts. We will be corresponding primarily through email, and adding us will prevent a delay in communication due to spam blockers.
Cell Phone: _________________________ Mailing Address:
__________________________ __________________________ __________________________
School Currently Attending: _________________________________________
(continued on back)
Intensive
How did you hear about ODI?
Please briefly describe your dance background:
Please select your technique levels:
Ballet Contemporary (modern) ___ Intermediate ___ Intermediate
PARENT/GUARDIAN INFORMATION
Parent/Guardian’s Full Name _____________________________ Email _______________________________________
* Please add [email protected] to your email contacts. We will be corresponding primarily through email, and adding us will prevent a delay in communication due to spam blockers.
Mailing Address (if different from student’s) __________________________
__________________________ __________________________ Phone (Day) _____________________ Phone (Night) _____________________
Emergency Contacts and Medical Form
Additional Emergency Contacts Name _____________________ Email _______________________________________ Phone (Day) _______________________ Phone (Night) _____________________ Relationship to student ___________________________ Name _____________________ Email _______________________________________ Phone (Day) _______________________ Phone (Night) _____________________ Relationship to student ___________________________ Physician
_____In case of a medical emergency, when parents/guardians and emergency contacts above cannot be reached, I authorize you to contact the physician of the above-named student.
_____I waive the right to list contact information for a physician. Physician’s Name ____________________________
Phone ______________________
Insurance
_____In case of a medical emergency, when parents/guardians and emergency contacts above cannot be reached, I authorize you to use the insurance information below.
_____I waive the right to list my insurance information. Name of Primary Policyholder ________________________________ Insurance Company ____________________________
Group number _________________________________ Policy number _________________________________ Medical Information
Please list below any allergies, illnesses, injuries, or medical conditions that may influence this student’s participation in our program. If your child has a food allergy, please attach a
written Allergy Action Plan detailing allergens, symptoms of a reaction, and steps to be taken in case of a reaction; and provide ODI Director with the necessary medications (such as Benadryl tabs, and Epi-pen or Emergency Response Kit). Oberlin Dance Intensive
cannot dispense, monitor, or maintain medication for any student EXCEPT in the event of an allergic reaction for which we have received an Allergy Action Plan and the necessary medication. In the liability release, you have specifically released us from liability resulting from actions taken in the case of a medical emergency.
Release Form
Liability Release Agreement
By signing below, I, [Participant’s name (if 18 years of age) or Guardian’s name (if participant is under 18 years of age)] _________________________________, on behalf of [Participant’s name] ______________________________ hereby release Oberlin College and the Oberlin Dance Intensive (ODI) and Oberlin College’s and ODI’s directors, agents, volunteers, and employees, and any other people officially connected with this program (the “released parties”) from any and all liability for damage to or loss of personal property, illness, or personal injury including but not limited to death, occurring during classes and events at or affiliated with ODI. I understand that by signing below, I am releasing any and all causes of action that I or the above-named participant, or our heirs, executors or assigns have had, have, or may have involving the released parties. I acknowledge that ODI cannot dispense, monitor, or maintain medication, and I specifically release the released parties from any and all liability resulting from action taken in the event of a medical emergency. I recognize that it is my responsibility to disclose to the ODI Director any condition,
including but not limited to illness, injury, chronic condition, disability or special need that may influence the above-named participant’s participation in ODI. I further authorize the use or disclosure of personally identifiable health information for the above-named participant should emergency treatment for illness or injury become necessary. I
understand that the participation in ODI classes is entirely voluntary and that the above-named participant may be removed from classes at the sole discretion of the Director in accordance with ODI policies. I understand that ODI directors, agents, volunteers, and employees are required by law to report suspected child abuse, and that any and all information I supply to ODI in any form may be passed on to the proper governmental authorities if child abuse is suspected.
Media Release
I, the undersigned, give my consent and permission to allow the above-named participant to be photographed, videotaped, interviewed, or otherwise recorded and to allow his/her name, age, school, ZIP code, likeness, voice, words, and/or appearance to be used in connection with future brochures, press releases, websites, publicity, advertising, promotional and/or commercial materials without reservation or limitations.
Parent Acknowledgement – ONLY FOR PARTICIPANTS UNDER 18 YEARS OF AGE This is to acknowledge that I, (Parent/Guardian) ____________________________________, am the legal guardian of the above-named student, a minor, and that I am eighteen years of age or older. I acknowledge that I have fully read and understood the information
contained in the Oberlin Dance Intensive Liability Release Agreement and Media Release and am responsible for compliance with the policies therein. I am signing this release on behalf of all parents or legal guardians of the above-named student now or in the future. Furthermore, I assume sole responsibility for informing my child and other adults involved in my child’s care of the contents of the Liability Release Agreement and Media Release. If accepted as a participant, the applicant agrees to abide by the regulations of Oberlin College. We understand that all fees must be paid prior to the beginning of instruction and that no deduction or refunds will be made for late arrival, early departure, or expulsion. Furthermore, we give our permission for the applicant to attend all functions and activities connected with the session, including any that may be held off-campus, transportation via school or coach bus with a professional driver.
Parent’s/Guardian’s Signature _____________________________ Name___________________________ Date______________
Participant Acknowledgement – ONLY FOR PARTICIPANTS OVER 18 YEARS OF AGE This is to acknowledge that I, (Participant) ____________________________________, am eighteen years of age or older. I acknowledge that I have fully read and understood the information contained in the Oberlin Dance Intensive Liability Release Agreement and Media Release and am responsible for compliance with the policies therein.
If accepted as a participant, I agree to abide by the regulations of Oberlin College. I understand that all fees must be paid prior to the beginning of instruction and that no deduction or refunds will be made for late arrival, early departure, or expulsion. Participant’s Signature _____________________________
PAYMENT
Payment is due in full at the time of registration.
In case of injury or special circumstances refunds are available, minus a $100 administrative fee. No refunds after June 1st.
Tuition: $585 (early registration) / $625 (regular registration) _______Commuter Fee: $120
Includes 5 lunches and 5 dinners
OR
_______Residential Fee: $300
Includes full room and board
___________________________________________________________________
_______ Check in the amount of $______________enclosed.
Write check to Oberlin College, with “ODI” in the memo line. Mail with registration form.
_______ Please charge my credit card in the amount of $______________. Credit Card Number: ___________________________________________ Expiration Date: ___________
Name as it appears Credit Card: __________________________________ Credit Card Code: __________
Billing Address: _________________________________________ Billing City: _____________________
Billing State : ____________ Billing Zip Code: ______________
________________________________________ ___________
