Child's Name:
Address:
City:
State:
Zip:
Email:
Birthdate:
Nature of Disability:
Parents' Names:
Best Phone Numbers
Name and age of sibling also participating in class (optional):
1. Is your child able to separate from you?
Name and phone of primary physician:
Name and phone of therapist
To help us evaluate your child’s suitability for the program and to prepare to best serve your child’s needs and goals, please answer the following questions:
2. What do you want child to get out of DancingUnlimited?

6. Describe recent surgeries
5. Can you describe your child's temperament? Easy going, high energy, self motivated, introverted, etc.
7. Does your child mind being touched? Is her/his skin sensitive?
3. Is there something specific you want us to work on for your child in the classes?
4. What age group is your child most comfortable with?
8. Please list any allergies we should be aware of.
9. Any other special information of which we should be aware:
Session(s) requested:
2/21-4/11, 2018
9/27-11/1, 2017
Interested in the performance also (must attend 2018 session)
 
To complete your application, please mail to GCB, 20 Commercial Way, Springboro OH 45066, the following:

-  A letter from the child's doctor with the recommendation for the child to participate, and including a statement certifying the child is a good match for the program.

- A letter from the child's therapist with a recommendation for the child to participate and goals for the child to work toward.
I understand that the director of Gem City, Ballet Barbara Pontecorvo, and Ellen Poti, former therapist, will make final decisions as to whether my child is a good fit for the program.
I ACKNOWLEDGE THAT PONTECORVO BALLET STUDIOS, GEM CITY BALLET AND THEIR EMPLOYEES, STUDENTS AND VOLUNTEERS, WILL NOT BE RESPONSIBLE FOR ILLNESS OR INJURIES.

To register, please fully complete and submit the form below. Please note the additional information to be submitted by mail.  Or you can download the brochure and submit both you application and other information all by mail.  Please call GCB at 937-550-9245 with any questions.

DancingUnlimited 2017
Registration
Gem City Ballet
20 Commercial Way
Springboro OH 45066
937-550-9245