After School Program Academic Enrollment Contract Form

Please complete this form to enroll in Kirov Academy of Washington DC's After-School Academic Program for the Winter/Spring 2021, January 11- May 31.

Your enrollment is complete and your spot is secured ONLY after you have completed this Enrollment Contract in its entirety and made the minimum payment of $55.00. By submitting the Enrollment Contract, you acknowledge that your first payment will be made as shown in the schedule below. If we have not received the required payment, the student will not be admitted to classes.

After payment is complete, you will receive a statement from the Finance Department (the final tuition amount depends on the program).

Please contact Mr. Stephen Gabb (academicASP@kabdc.org), our After-School Academic Program Head if you have any questions about the After-School Academic Program.

Class Selection

Please choose the appropriate After-School Academic Class*

Package Options*

20 classes per semester (2-3 classes per week) $475

Applicant Information

Please put student's information here

Student Name*

First Middle Last

Date of Birth*

Current Age*

Academic Grade for 2021-2022*

Type N/A if not applicable

Student Gender*

Male
Female

Student Email

Student Primary Phone*

Student Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian 1 Information

Parent/Guardian 1 Name*

First Last

Parent/Guardian 1 Relation to Student*

Parent/Guardian 1 Gender*

Male
Female
Other

Parent/Guardian 1 Lives with Student*

Yes
No
Other

Parent/Guardian 1 Emergency Contact?*

Yes
No
Other

Parent/Guardian 1 Email*

Parent/Guardian 1 Phone*

Parent/Guardian 2 Information

Would you like to fill out information for a 2nd parent/guardian?*

Yes
No

Parent/Guardian 2 Name*

First Last

Parent/Guardian 2 Relation to Student*

Parent/Guardian 2 Gender*

Male
Female

Parent/Guardian 2 Lives with Student*

Yes
No

Parent/Guardian 2 Emergency Contact?*

Yes
No

Parent/Guardian 2 Email*

Parent/Guardian 2 Phone*

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Medical Insurance Information

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Primary Insurance Provider*

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Insurance Phone Number*

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Policy #*

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Group #*

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Subscriber Full Name*

First Middle Last

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Relationship to Applicant*

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Subscriber Birthdate*

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Allergies

Please list below any allergies or health conditions that could affect the participant's class participation

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Entry/Exit Permissions

Sign In/Out Procedures:

Adults will sign in/out at the front desk; children must be signed in/out by an adult whose name must be on our list of parents/adults allowed to pick them up/drop them off.

Adult visitors will be given a badge to wear while in the building that must be returned upon signing out.

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Please list the names of any adults, other than parents or guardians, who will be coming with or picking up the applicant. Only those listed will be allowed to enter the building and/or pick up the applicant.*

If you do not wish to add anyone or if this is not applicable, type N/A.

Media Release Form

All enrolling students must read over and submit the Media Release Form prior to filling out the Enrollment Contract.

Please confirm that you have read and submitted the Media Release form before completing this Enrollment Contract.*

Click this on "Media Release Form" to read and submit.

Yes, I have read and submitted the Media Release Form.

Enrollment Contract

By signing this Enrollment Contract, the Parent/Legal Guardian acknowledges the following provisions:

1. I acknowledge that Kirov Academy of Washington, D.C. (“the Academy”) will issue refunds based on withdrawal policies outlined in the ASP Handbook. Refunds will be authorized according to each department’s refund policy. Participation is suspended until minimum payment is received. All withdrawal requests must be made through the Withdrawal Form after notifying the Program Head.

2. I understand this is an enrollment and tuition commitment for the program duration regardless of early withdrawal or missed classes.

3. I acknowledge that the Academy reserves the right to retract enrollment at any time, for any reason, such as: behavior, attendance, or late payments.

4. I agree that the Academy is not liable and is held harmless from any losses, injuries, damages or expenses related to the above-named applicant’s participation as well as to visitors in association with the above-named applicant. Any and all claims against the Academy are waived. In turn, any damage and/or harm caused by the applicant and/or visitors will be the responsibility of him or herself, or the parent/legal guardian.

5. I acknowledge that the above-named applicant registering for artistic classes may be physically touched to adjust and improve their posture or position from time to time during his/her training and will not hold the Academy liable for such necessary physical adjustments.

6. I have read over and signed the Media Waiver form as to how the applicant’s image/video may or may not be used for publicity, press, and/or in-house purposes.

7. The Academy reserves the right to make any changes to the program or schedule as needed, with or without notice.

8. I understand that the Academy is not responsible for classes cancelled due to inclement weather or other "city-wide emergencies." Make up classes are determined by the Academy on a case-by-case basis and are not guaranteed.

Applicant or Parent/Legal Guardian Electronic Signature

I have read and agree to all provisions of this Contract. All electronic signatures on this form and their related fields are treated by Kirov Academy of Washington, D.C. as a wet signature (a physical, handwritten signature on a paper form). I agree to enter into this Contract by electronic means.

Consent*

*The electronic signature below and its related fields are treated by Kirov Academy of Washington, D.C. as a wet signature (a physical, handwritten signature on a paper form). I (We) agree to enter into this Contract by electronic means. I (We) have been provided with the amounts that I (we) must pay according to the 2020-2021 Classes and Schedule and I (we) agree to pay this amount.

I (We) have read and agree to all provisions of this Enrollment Contract.

Please type your first and last names:*

Date of Signature*

Payment

Enrollment Fee/Evaluation Fee*

Price:

3% Convenience Fee*

Price: $0.00

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Select Payment Plan:*

Full Amount
Payment Plan

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Choose your program*

*not applicable for Movement & Rhythm for Little Dancers and Pre-Ballet*

Ballet 1 (Ages 7-8) $875
Ballet 2 (Ages 9-10) $1,150
Ballet for Serious Dancers (Ages 10-13) $2,575

Total

$0.00

Credit Card

Card Details

Cardholder Name

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PDF

After-School Program Academic Enrollment Contract Form

Class Selection

Applicant Information

Parent/Guardian 1 Information

Parent/Guardian 2 Information

Medical Insurance Information

Entry/Exit Permissions

Media Release Form

Enrollment Contract

Applicant or Parent/Legal Guardian Electronic Signature

Payment