STUDENT INFORMATION: (please print)
Transcription
STUDENT INFORMATION: (please print)
DANCE THEATRE OF HARLEM SCHOOL REGISTRATION APPLICATION Fall/Spring Sessions 2015-2016 Status: New Student Returning Student F-1 VISA Date: ______________________ STUDENT INFORMATION: (please print) Student’s Name: (Last) _________________________ (Middle) (First) / Email Address Home Phone # ____/_____________________ Cell Phone # __________________________________________________________________________________________________ Student’s Local Address: City State Zip Code Date of Birth ________ Age ______ Male Female Citizenship Status ____________ Ethnicity_____________________ Height/Estatura: ________ Weight/Peso: ____________ Street Shoe size: __________ Clothing size____________________ Current Academic School: _____________________ ____________Please check one: Public Private Charter Grade Level: __________ Previous Dance Schools: ____________________________________________________________ Parent/Guardian Information (please print) __________________________________________ Parent/Guardian First and Last Name ___________________ Relationship to Student ______________________________ Cell Phone # __ ___________________________________________________________________ City & State Zip Code Parents’ E-mail Parent/Guardian Address ________________________________ Parent/Guardian Place of Business _________________________ Work Phone Household income range: None $5,000-$19,999 $20,000-$40,999 ___________ Emergency Contact (other than parent) ___________________ Relationship to Student _________________________ Position $50,000-70,999 $80,000-$100,000+ ______________________ _________________ Home or Work # Cell Phone # Where did you hear about our school? Reputation Media Recruitment Word of mouth Family Member Other How did you audition for DTHS? General Audition ___________________________________________________ Parent/Guardian Signature or Student’s Signature (if over 18) Online In-Class Audition ______________________________ Date For Dance Theatre of Harlem School Use ONLY-Do Not Write below this line. Program: Tendu Upper School Lower School Level: ____________________________________ Registration Fee ($60.00): Date Received___________ 466 West 152 Street, New York, NY 10031-Phone: 212.690.2800-Facsimile: 212.690.8736 Website: www.dancetheatreofharlem.org DANCE THEATRE OF HARLEM SCHOOL APLICACIÓN PARA ADMISIÓN Sesión Otoño/Primavera 2015-2016 Estatus: Alumno Nuevo Alumno Pre-existente F-1 VISA Fecha: _____________________ INFORMACION DEL ALUMNO: (favor de usar letra molde) Nombre del alumno: (Apellido) _________________________ (Segundo Nombre) (Primer Nombre) ________________________________________________________/____________________________/_________________ Correo Electronic Telefono Casa Telefono Mobil _______________________________________________________________________________________________________ Domicilio local del alumno Ciudad Estado Codigo Postal Fecha de Nacimiento________ Edad_______Hombre Mujer Estatus de Ciudadania___________Etnicidad_____________ Estatura: _____________Peso: __________________ Street Shoe size: ____________ Clothing size____________________ Escuela Academico Actual:_______________________________ Marque Uno: Publico Privado Charter Grado: ___________ Fecha de Graduacion______________________ Escuela de Bailo Previos__________________________ Informacion de los Padres o Tutor: (favor de usar letra molde) ___ Padres/Tutor Primer Nombre y Apellidol ___________________ Relacion al aumno ___________________/___________________ Telefono Casa Telefono Mobil ____________________________________________________________________________________________________ Padres/Tutor Domicilio Ciudad Y Estado Codigo Postal Correo electronic ___________________________________ Padres/Tutor lugar de trabajo ___________________/_______________ Telefono Trabajo Telefono Mobil Ingreso economico: Ninguno $5,000-$19,999 ________________________ Posicion $20,000-$40,999 $50,000-$70,999 $80,000-$100,000+ _________ ___________/______________/___________________________/____________ Nombre Contacto de emergencia (aparte de los padres) Relacion al alumno Telefono Casa 0 Trabajo Telefono Mobil ¿Cómo se entero de nuestra escuela? Reputacion Medios de Noticias Reclutamiento Chisme Familia Otro ¿Cómo audición para DTH? audición en general en línea audición en clase _____________________________________________________________ Firma del Guardián/Tutor Principal o Alumno (si mayor de 18) _________________________ Fecha Para el uso de Dance Theatre of Harlem unicamente-Favor de no escribir despues de esta linea Program: Tendu Upper School Lower School Level: ______________________________________ Registration Fee ($60.00): Date Received__________ 466 West 152 Street, New York, NY 10031-Phone: 212.690.2800-Facsimile: 212.690.8736 Website: www.dancetheatreofharlem.org DANCE THEATRE OF HARLEM SCHOOL Doctors’ Health Statement Parents please note students are required as part of their registration to undergo a physical every calendar year. Date of Examination: _____________________ ____________________________________________ Last Name, First Name Sex: F M Initial Address: ______________________________________ DOB: ____________ _____________________________________________________ City, State Zip Code Age: _______ Telephone: ________________ PARENTS: A HEALTH STATEMENT IS NOT VALID WITHOUT A PARENT/GUARDIAN SIGNATURE After examination by a physician, the results of which appear on the following page, I believe my child to be in proper physical condition for participation in the dance program at the Dance Theatre of Harlem School. _____________________________________________ Signature of Parent/Guardian ________________________ Date I hereby authorized Dance Theatre of Harlem School to provide emergency care as needed to my child including but not limited to emergency room care. I understand that Dance Theatre of Harlem School is not responsible for payment of hospital services rendered. _____________________________________________ Signature of Parent/Guardian ________________________ Date THE FOLLOWING MUST BE COMPLETED BY THE EXAMINING PHYSICIAN ONLY I understand that my patient wishes to enroll in the dance school referenced above, a program which may involve strenuous exercise. After an examination, the results of which appear on the following page, I find no systemic, neurological, orthopedic and/or cardio-vascular medical condition(s), which would prevent participation in the dance program at the Dance Theatre of Harlem School. __________________________________________________________________________________________________ Physicians name and address (Please type or print legibly) __________________________________________________________________________________________________ City State Zip Code Telephone number _________________________________________ PHYSICIAN’S SIGNATURE & OFFICIAL STAMP ____________________________________________________ Physician License Number 466 West 152 Street, NY, NY 10031-1814 Tel:212.690.2800 FAX:212.690.8736 www.dancetheatreofharlem.org Date of Examination: _________________________ Record of Physician’s Examination for __________________________________________________________ Last Name, First Name Initial Does the patient require any of the following: Eyeglasses: Yes No Hearing Aid: Yes No Other support device: Yes No * REVIEW OF SYSTEMS * Allergies: Head & Eyes: Ears, Nose, Throat & Mouth: Cardiovascular: Respiratory: Gastro-Intestinal: Genito-Urinary & Gynecological: Neurological: Skin & Endocrine: Muscular-Skeletal: Infectious: Is the patient currently under treatment? If yes, please explain _____________________________________________________________________________________________ _____________________________________________________________________________________ _________________________________________________________________________________________ Does patient take any medications? No Yes, please provide frequency and condition below _____________________________________________________________________________________________ _____________________________________________________________________________________________ _________________________________________________________________________________ Are the patients’ immunizations up to date? No, please explain below Yes, please provide a copy of the Record of Immunizations along with this form. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _________________________________________________________________________________ 466 West 152 Street, NY, NY 10031-1814 Tel:212.690.2800 FAX:212.690.8736 www.dancetheatreofharlem.org DANCE THEATRE OF HARLEM SCHOOL MEDICAL HISTORY Parents or students over 18 years are required to answer ALL questions on this form, if the question does not apply write N/A in the space provided. PLEASE PRINT CLEARLY Date: _______________________________ Student Name: ___________________________________ LAST NAME, ___________________________________ FIRST NAME Please list any allergies (food, medication etc.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Please identify any medical conditions. (If you check a condition please provide detail below) Asthma Diabetes ADD Scoliosis ADHD Seizures Mental/Emotional Disorder or Imbalance Speech/Hearing Challenges Muscular Injury (provide details below) Previous bone injury (Give details) Other (Give details): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Any prescribed medications currently taken? If so, please provide name, dose and frequency below: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Please list any recent injuries that the student may be recovering from, or old injuries that may impact training: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Form completed by: Print Name: ______________________________ Parent Student Signature: _____________________________Date:___________ PARENT’S CODE OF CONDUCT It is the intention of this program to promote respect for all participants within all levels of the Dance Theatre of Harlem School. It is expected that all parents/guardians of participants read and understand the Parent’s Code of Conduct and continue to observe and follow all the principles contained within the Code throughout the year. 1. I will remember that my child participates for his/her enjoyment. I will not force my child to participate in the arts. I will try to make it FUN! Initial: ______ 2. I will insist that my child participates in a safe and healthy environment. I will support an arts environment that is free of disrespectful behavior, inappropriate conversations, public critiques of student artists or the program, and I will refrain from this behavior at all times. I will encourage my child to abide by the rules and to resolve conflict without resorting to disrespect, hostility or violence in person, in verbal communication, through social media, etc. I will and I will encourage my child to respect and show appreciation for the staff and volunteers who give their time to the success of the program for my child. Initial: ______ 3. I will teach my child that doing one’s best is the primary goal so that my child will never feel defeated by the outcome of casting or placement. I will never ridicule or yell at my child for his/her casting or placement. I will not compare my child’s casting or placement to other dancers openly in public or in front of my child. I will make my child feel successful every time by offering praise for working hard and following through on his/her commitment. Initial: ______ 4. I will remember that children learn by example. I will applaud talent by both my child and other student artists. I will not be critical of, or embarrass any student artist, at any time. Initial: ______ 5. I will leave the artistic vision, programming and casting to the artistic staff. I will never question the artistic team’s judgment, intention or honesty in public. I will trust that decisions have been made with integrity and strategy for the overall good of the program and the participants. I will encourage my child to participate in a manner consistent with the program’s philosophy. Initial: ______ 6. I will emphasize skill development and a serious approach to training (classes, rehearsals, and production weeks) and explain how skill development and consistency in training will benefit my child. I understand the benefits from participating in a rigorous arts training program, the commitment, the discipline and the social skills learned and acquired. I will attempt to learn about the arts world so that I may best support my child’s development in the field. Initial: ______ 7. I will communicate and report any concerns regarding inappropriate behavior to a member of the Artistic/Program Staff (School Director, Student Affairs Officer, School Administrator or Faculty). I will communicate all questions about the programming through the proper channels as well, respectfully understanding the role of each member of the staff. I will communicate in a professional manner at an agreed upon time and place, respecting the personal time of the staff. Initial: ______ I have read and understand the above Code of Conduct, and agree to abide by it at all times. I understand that if I do not follow this Code of Conduct, I may be asked to cease an activity (such as observing in the hallways or volunteering backstage) or I may be asked to withdraw my child from the program. ___________________________________________________________________ Parent/Guardian Signature ______________ Date DANCE THEATRE OF HARLEM SCHOOL TRAVEL PERMISSION FORM Please circle the response that applies to your child and be sure to sign and return this document to the school staff. This form is for students 16 years or younger only. I, _____________________________________do /do not (circle one) hereby give my son/daughter __________________________________ permission to leave the Dance Theatre of Harlem School without adult supervision, and to travel alone to a predetermined destination. The list of persons below, are individuals who are permitted to escort my child from the Dance Theatre of Harlem premises in my absence. 1. ______________________________________________ 2. ______________________________________________ 3. ______________________________________________ 4. ______________________________________________ Once my child leaves the DTHS building, I release DTH and its employees of all responsibility for the safety and welfare of my child. I agree to notify the school staff by phone or email, if there are any changes to this initial list. _____________________________________ Parent’s Signature ________________ Date _________________________ ___________________ Child’s Name ________ Age Class/Program DANCE THEATRE OF HARLEM SCHOOL WAIVERS AND RELEASE AGREEMENTS I am not aware of any medical condition my child has which would preclude him or her from participating in dance activities. I understand there is a definitive risk of injury associated with dancing and that such injuries include, but are not limited to bruises, dislocations, broken bones, torn or damaged muscles and ligaments, paralysis and even death. I understand that such injuries may be caused in whole or in part by the student (my child), or by the actions or inactions of other students or instructors. 1. In consideration of being accepted for dance instruction by the Dance Theatre of Harlem School (DTHS), and in further consideration of the expertise and achievements of instructors at DTHS and the limited number of students that may be accepted by DTHS, my child and I agree to all of the following, which shall bind me and my child, and also my heirs, assigned executors and administrators: a. I agree to instruct my child to immediately stop performing any activity if he or she feels any pain, dizziness, light-headedness, or any other symptoms, and to immediately report those symptoms to the instructor. I also agree to instruct my child to carefully follow the instructors’ directions, to ask for additional directions if he or she does not understand any particular activity, and to immediately stop any activity which he or she is not competent or confident enough to perform. Initial: ______ b. To the fullest extent permitted by law, I agree and represent that I and my child assume the risk and responsibility for any and all injuries to my child that he or she sustains while performing any dance activities, including any and all costs and damages that are a consequence of such injuries, and whether such injuries, costs and damages were caused in whole or in part by DTHS, instructors, students or employees. Initial: ______ c. To the fullest extent permitted by law, I and my child agree to defend, indemnify and hold harmless DTHS and their instructors, agents, employee, contractors, clients and students, from and against all claims, costs, damages, losses and expenses, including but not limited to attorney’s fees, arising out of or resulting from my child’s performance or other participation in any dance or aerial activities, regardless of whether or not such claim, cost, damage, loss or expense was caused in part by a party indemnified hereunder. Initial: ______ I have fully read and agree to all of the above, my child and I make this agreement and the representations herein in order to induce Dance Theatre of Harlem School to accept my child as a student for dance instruction. Limited Use Photographic Release For and in consideration of my engagement as a student by the Dance Theatre of Harlem School (hereafter referred to as DTHS) on terms hereinafter stated, I hereby give the Photographer/Videographer and DTHS, their legal representatives and assigns, those for whom the Photographer/Videographer and DTHS are acting, and those acting with their permission, the right to copyright and/or use, reuse and/or publish, and republish the photographic pictures/film of me taken during the course of my study at DTHS or at any School performances. I hereby waive any right to inspect or approve the finished photograph(s)/video(s) prior to publication. I hereby release, discharge and agree to save harmless the Photographer /Videographer and DTHS, their representatives, assigns, or any other person or persons, corporation or corporations, for whom they might be acting, including any firm publishing and/or distributing the finished product, in whole or in part, from and against any liability as a result of its publication or distribution of the same. I certify that I am suffering under no legal disabilities and that I have read the foregoing release, authorization and agreement, before affixing my signature below, and warrant that I fully understand the contents thereof. 9/8/2015 __________________________________________ SIGNATURE PARENT/GUARDIAN _________________ DATE __________________________________________ SIGNATURE STUDENT __________________ DATE DANCE THEATRE OF HARLEM SCHOOL General Rules and Regulations The Rules and Regulations are in place to support the Dance Theatre of Harlem School’s mission to provide training in the art of dance within a safe, nurturing learning environment for all students. Dance Theatre of Harlem School is accredited by The National Association of Schools of Dance, and is listed as an institution of higher education by the U.S. Dept. of Education. The Dance Theatre of Harlem School is authorized under Federal law to enroll non-immigrant students and will assist them with acquiring an F-1 Visa. Students are strongly encouraged to familiarize themselves with the Rules and Regulations of the Dance Theatre of Harlem School. Any infraction of these Rules and Regulations is frowned upon and could result in suspension or expulsion from our program. In the interest of the overall security of our students and building and in keeping with the building/fire/insurance codes, we respectfully ask that you follow the guidelines listed below: Students accepted into our program are required to submit all necessary forms in order to ensure complete and timely registration. The submission of these forms is necessary prior to the start of classes. Students are required to submit timely payment of the Registration, Activity and Costume fees, along with full Tuition or a 1st installment payment as permitted through your approved Payment Plan. The submission of said payments is necessary prior to the start of classes. Students are required to: 1. Be on time, 2. Attend classes regularly according to their program schedule, 3. Adhere to DTHS dress code, 4. Apply themselves and commit to the dance training offered at DTHS, always demonstrating a respectful attitude toward instructors and staff. Scholarship students must participate in performances as required by the Dance Theatre of Harlem School and be available for rehearsals. All students are required to sign in and out every time they enter the building for class. Students should arrive at least 15-20 minutes early to dress and warm-up before class. All Students are required to keep a journal of their experience at DTHS, and to include input from teachers regarding corrections and exercises for each class. Students must bring the journal to each class and have it available upon request. Journals are checked periodically. Lockers are assigned at the beginning of the session depending upon availability. Generally lockers are assigned to Lower and Upper School program students who attend DTHS more than once per week. All students who attain a locker are advised to use a lock at all times to keep belongings safe. Tendu Program students should place belongings in a dance bag and leave it with an adult or bring it to the studio with them. DTHS is not responsible for lost or stolen items. Our Lost and Found area is located at the front desk behind the receptionist. Changing clothes is permitted ONLY in the locker rooms. Students are NOT PERMITTED to change clothes in the lobby, stairwells, hallways or public bathrooms. Students may use the Basement Lounge and the second floor Terrace (with permission) during breaks and to consume food. Water fountains for students are located in the Basement and second floors only. Food consumption is not allowed on the lobby level, 2nd or 3rd floors or in the stairwells. Do not consume food in the Locker Rooms. DTH recycles! Kindly dispose of your cans, bottles and plastic items in the blue recycling bins and place all other trash in regular trash receptacles. Except for the refrigerator and microwave, kitchen appliances are not to be used by students. Students are NOT permitted in the Administrative Offices unless they are conducting business with Staff/Faculty or if they are waiting to be picked up by an adult. Students are NOT permitted to use the elevator to go to classes, except in cases where physically necessary due to injury. OVER 9/8/2015 General Rules and Regulations (page 2) SOCIAL MEDIA: Students may not use social media sites to publish disparaging or harassing remarks about DTHS community members, including, but not limited to, faculty, staff, and students. Students who choose to post editorial content to websites or other forms of online media must ensure that their submission does not reflect poorly upon The Dance Theatre of Harlem. Dance Theatre of Harlem School takes bullying in all forms very seriously! Students who are accused of bullying will be called to conference with their parents, the school administrator and the school artistic director. Bullying includes, but is not limited to verbal and/or physical abuse, intimidation, and abuse via social media, phone, email, etc. Cell Phones must be turned to vibrate/manner mode upon entering the building and must be left in the locker room or with your belongings. A cell phone being used in the studio will be confiscated and a parent will be required to come to DTHS to pick it up. Students are not allowed to receive or make telephone calls at the Front Desk or in the Administrative offices unless there is an emergency. Only in an emergency situation will School Administrative staff take a message for a student. A public telephone is available on the basement level. Gum chewing, profanity, smoking, drugs, alcohol and weapons are strictly prohibited at Dance Theatre of Harlem School. Any student caught with drugs, alcohol or weapons will automatically be expelled. Smoking directly in front of the building’s entrance is strictly prohibited. Any student found pilfering or defacing DTHS property will be permanently dismissed. FALL/SPRING SESSION EVALUATIONS: All students will receive written evaluations at least once per semester. A Jury Assessment is required at the end of the Spring semester for Lower and Upper School students, during which each student will be assessed before a panel of instructors and artistic directors. Evaluations are based on the following criteria: Attendance, Attitude, Concentration, Improvement, and overall Performance. Our Spring Performance is mandatory for all students and is an essential part of the overall program. SICK DAYS: Students are required to email the Student Affairs Officer Karen Farnum-Williams or call the Attendance Line, ext. 424, if they are unable to attend class. A doctor’s note will be required from students who are sick more than three (3) consecutive class days. ABSENCES & LATENESS: During our 32 week program, Lower School Program students in Levels (1-3) are allowed six (6) absences, Upper School Program Level (4-7) students are allowed eight (8) absences. Tendu students are allowed four (4) absences. Any additional absences may be accepted at the discretion of School Administration, if an acceptable explanation is provided in writing by the parent/guardian. Excessive absences or lateness may result in a warning, probation, loss of award (e.g. scholarship /financial aid), suspension or expulsion at the discretion of the School Administrator and School Artistic Director. WITHDRAWAL: A Formal Letter of Withdrawal must be submitted to the Student Affairs Officer via mail or email in order to constitute an official withdrawal from the School. (Note: Refer to the Admission Procedures page under DTHS Refund Policy) NOTES TO PARENTS/GUARDIANS: 1. One Parent/Guardian should accompany the student to Dance Theatre of Harlem at a time. Parents/Guardians, siblings or friends must wait in the basement lounge area. Under aged siblings or friends must be accompanied by an adult at all times. Running, yelling, climbing or horseplay of any kind is strictly prohibited. 3. Parents/Guardians are not allowed to use the elevators unless physically necessary. 4. Parents/Guardians are not allowed at studio doorways or in the dance studios for observation, or waiting in the lobby while classes are in session. Class observations are only permitted during Open School Week. Please consult the School Calendar for dates. 5. Flash photography or videotaping is prohibited during classes and or performances unless other arrangements have been made by DTHS staff. 6. Contact the School Administrator, Student Affairs Officer or Front Desk for any Emergency at 212.690.2800. I agree to abide by these Rules & Regulations: _____________________________________________________________________________________________________ Signature of Student 9/8/2015 Signature of Parent/Guardian Date 9/8/2015 DRESS CODE FALL/SPRING 2015-2016 SESSION 1. DTHS requires students to report to class in proper DTHS Uniform – no leg warmers, sweats, shorts, head coverings, multicolored leotards, etc. are allowed. Jewelry can be dangerous while dancing and should not be worn in class; students are encouraged to leave all jewelry at home. Only stud earrings are allowed in class. 2. The “DTH Look”: DTHS requires all female students wear flesh toned tights as close to the student’s skin tone as possible, and to spray their ballet slippers and pointe shoes to match their tights. This will prevent a break in the visual “line”. That is, when you see one shade of skin tone at the top of the body, you should see the same below. Female dancers should use shoe spray to match their shoes to their tights. Nu Life Color Spray by Kiwi and Meltonian are brands often used at DTHS and are readily available at the DTHS Boutique. Shoes are to be sprayed at home. Spraying shoes at DTHS or outside the DTH building is strictly prohibited. 3. Tights: Students taking Modern, West African or Gymnastics must take class in bare feet, so it is necessary to purchase “transitional tights” which are available at the DTHS Boutique and at all dancewear stores. Students are expected to wear tights without runs or holes. 4. DTHS Uniform - Females: At least one full set of DTHS Leotard and Tights is required for all females. Leotards are color coded according to DTHS Program and Level as follows: Lower School Upper School Tendu Program Level 1, 2, 3 Level 4, 4AP, 5, 5AP, 6AP, 7AP, Beginner Teens All Levels White Tank Royal Blue Camisole Navy Blue Tank 5. DTHS Uniform - Males: The Male uniform for all levels consists of a fitted white tank top or T-shirt (suggestion: dance shirts for males fit better than regular t-shirts and last longer, and can be purchased at all dancewear stores). Tights/Leggings must be black, coupled with a dance belt (older boys), white socks and white ballet shoes. Shoes must be kept clean and un-scuffed. 6. We suggest all dance attire including shoes be labeled (inside) with the student’s name, to prevent loss. 7. HAIR: Female students must wear their hair swept back and up in a secured ballet bun. Braids are accepted, but should not exceed a length and thickness that prohibits a safe and secure, appropriately sized ballet bun. Females with short hair must keep hair neat, secure and away from the face. Male students must wear their hair neat and short, or long hair must be secured back and away from the face. No heavy facial hair. Nails must be kept trimmed for all students. **There is a grace period of one week to arrive to class in proper dress code attire. Uniforms can be purchased in the DTHS Boutique or at the following suggested dance retailers: Capezio – 201 Amsterdam Ave. & 69 St. 212.586.5140 Capezio – 1650 Broadway at 51st St., 2nd fl. 212-245-2130 Capezio – 1651 Third Avenue, 3rd Fl. 212-348-7210 The Dance Shop – 188-06 Union Turnpike, Queens 718-464-8980 466 West 152 Street, New York, NY 10031-Phone: 212.690.2800-Fax: 212.690.8736 Website: www.dancetheatreofharlem.org 9/8/2015