Registration Form

Child Liability Form

"*" indicates required fields

Step 1 of 2

Please Note
Submitting a waiver does not guarantee a space in class.
The office must be contacted to secure spaces in programs.
To ensure a successful experience for all students at Break the Barriers,
a student may be transferred to a class that is more
beneficial to them at the discretion of the Director.

Family Information

Parent 1 First Name*

Parent 1 Last Name*

Address*

Street Address Address Line 2 City State ZIP Code

Parent 1 Preferred Phone Number*

Parent 1 Alternate Phone Number*

Parent 1 Work Place

Parent 1 Work Phone Number

Parent 1 Email Address

Parent 2 First Name

Parent 2 Last Name

Parent 2 Preferred Phone Number

Parent 2 Alternate Phone Number

Parent 2 Work Place

Parent 2 Work Phone Number

Emergency Medical Authorization

Should it become necessary for my child or ward to have emergency medical treatment while participating in activities associated or affliated with Break the Barriers, Inc. (Hereafter “BTB”) I hereby authorize BTB personnel to use their jugdment in obtaining emergency medical services. I further authorize any individual selected by BTB personnel to render such emergency medical treatment to my child or ward as deemed necessary and appropriate. I understand that BTB is not responsible for paying the medical or hospital costs incurred on behalf of child or ward. Consequently, I understand and agree that all such costs shall be my sole responsibility.

Emergency Contact Name (other than parent)*

Emergency Contact Phone Number*

Family Doctor Name

Family Doctor Phone Number

Signature for Emergency Medical Authorization*

Date Signed*

How many students are you registering?*

Please enter a number from 1 to 6.

Relationship to the student*

Parent

Foster Parent with Exparte

Legal Guardian with court papers

Foster Parents and Legal Guardians must provide BTB with the appropriate documents one week before starting class. Students cannot begin class without appropriate documents.

Student Name

First Last

Birthdate

Gender

Ethnicity

Student Health History (Check all that apply)*

Student 2

Relationship to the student*

Parent

Foster Parent with Exparte

Legal Guardian with court papers

Foster Parents and Legal Guardians must provide BTB with the appropriate documents one week before starting class. Students cannot begin class without appropriate documents.

Student Name

First Last

Birthdate

Gender

Ethnicity

Student Health History (Check all that apply)*

Student 3

Relationship to the student*

Parent

Foster Parent with Exparte

Legal Guardian with court papers

Foster Parents and Legal Guardians must provide BTB with the appropriate documents one week before starting class. Students cannot begin class without appropriate documents.

Student Name

First Last

Birthdate

Gender

Ethnicity

Student Health History (Check all that apply)*

Student 4

Relationship to the student*

Parent

Foster Parent with Exparte

Legal Guardian with court papers

Foster Parents and Legal Guardians must provide BTB with the appropriate documents one week before starting class. Students cannot begin class without appropriate documents.

Student Name

First Last

Birthdate

Gender

Ethnicity

Student Health History (Check all that apply)*

Student 5

Relationship to the student*

Parent

Foster Parent with Exparte

Legal Guardian with court papers

Foster Parents and Legal Guardians must provide BTB with the appropriate documents one week before starting class. Students cannot begin class without appropriate documents.

Student Name

First Last

Birthdate

Gender

Ethnicity

Student Health History (Check all that apply)*

Student 6

Relationship to the student*

Parent

Foster Parent with Exparte

Legal Guardian with court papers

Foster Parents and Legal Guardians must provide BTB with the appropriate documents one week before starting class. Students cannot begin class without appropriate documents.

Student Name

First Last

Birthdate

Gender

Ethnicity

Student Health History (Check all that apply)*

Please explain any of the above, including dates of accidents/injury/illness/surgery

Please list any medications taken regularly & any special instructions regarding medical treatment

Waiver and Release from Liability: To Break the Barriers, Inc., I hereby consent to the above named student(s) participating in programs, performances, and classes which are conducted by or affiliated with Break the Barriers, Inc. I acknowledge that the programs, performances and classes might expose participants to certain risks, which include, but are not limited to; risks related to the associated physical activities and other risks, some of which may not be specifically foreseeable. I certify that I am the parent or guardian of the participant(s) identified above. I acknowledge that my child or ward’s participation is voluntary and undertaken with full assumption of all risks associated with the programs, performances, and classes including the risks listed above and all other risks that are not specifically listed above. This release is intended to discharge in advance Break the Barriers, Inc., and its officers, Board of Directors, Advisory Board Members, employees, volunteers, and agents against any and all liability arising out of negligence or carelessness on the part of the entities and persons mentioned above. I hereby waive, release, and discharge on my child’s or ward’s behalf and on behalf of his/her heirs, dependents, estates and any other representatives, including myself any and all claims which may exist or which may hereafter occur, against Break the Barriers, Inc., and its officers, Board of Directors, Advisory Board Members, employees, volunteers, and agents for any injury, accident, illness, or death arising out of or in any way releated to the programs, performances, classes and other events which are sponsored or affiliated with Break the Barriers, Inc.

Signature for Waiver and Release From Liability*

Date Signed (mm/dd/yyyy)*

Break the Barriers Rules & Information

Payment Information

No Refunds or Credits of fees paid.
Monthly fees are due before the last business day of each month. Fees paid on the 1st are considered late and a $10.00 late fee will be charged.
Students will be dropped from class if payment has not been received and the office has not been contacted for payment arrangements
Payments can be made over the phone using Visa or Mastercard. Payments may also be set up through your online banking and checks will be sent to BTB each month. There will be a $25 service charge for all returned checks. Only cash will be accepted to clear a returned check.
All students must give a two week notice when dropping their class. Students have the option of finishing out the current month or stopping the date of the notice with No Credit to their account.
Due to our large number of students and limited availability – BTB is not able to accommodate make-ups for classes missed.
Break the Barriers is a non-profit corporation. We need to keep classes full so that we can retain staff and accommodate our waiting lists.

BTB does not charge more for the months with five weeks. Those extra days of classes are traded for the major holidays that BTB is closed. BTB is closed one week for Spring Break, Memorial Day, July 4th, Labor Day, Thanksgiving week and one to two weeks in December for Winter Break. We remain open for most Monday holidays, including Presidents’ Birthdays, Veteran’s Day and Martin Luther King’s Birthday.

Dress Code

Break the Barriers is a non-profit corporation with a very large outreach to all abilities and body types. We have a strict dress code that is welcoming to everyone.

FOR ALL CLASSES

Students need to wear proper attire that does not restrict movement.
NO tummies showing
No low-cut shirts (front or back)
No spaghetti straps (tank-style shirts must have a minimum 1 inch shoulder strap)
All shorts must have at least a 6 inch inseam (no high cut bottoms or short shorts), biker shorts with a 6-inch inseam may be worn under shorts that do not have a 6-inch inseam
NO Jewelry, NO belts, NO hard sole shoes (except tap shoes for dance classes)
Long hair must be tied back – NO EXCEPTIONS!
No Gum

FOR AERIAL DANCE FITNESS

Please do not wear shorts. Leggings that reach at least to the middle of your shin and are tight fitting and hug the body are recommended to protect your skin from fabric burns
No loose fitting shirts or pants, as they will get caught in the silks
Break the Barriers appropriate leotards and shirts with sleeves are recommended to protect your arms from fabric burns For male students, basketball shorts are not recommended as they are too baggy and will get caught in the fabric. Please choose an exercise pant that is not too loose

FOR AQUATICS

Water resistant sunscreen
One-piece bathing suits (mandatory for all female students, including parents)
Swimmers who are in LTS3 and above must wear a swim cap
Swimmers in lower level classes, we ask that their hair is tied back

FOR ARCHERY

Must wear closed toe shoes

FOR DANCE

Girls Ballet

dark solid leotard
pink tights
pink split-sole ballet shoes (please tuck in elastic ties)

Boys Dance Classes

fitted shirt
shorts
black split-sole ballet or jazz shoes

Hip Hop

fitted t-shirt
dance pants, shorts, or joggers
clean, supportive tennis shoes

Contemporary Classes

fitted t-shirt
dance pants, shorts, or joggers
jazz shoes or barefoot

Contemporary Classes

fitted t-shirt
dance pants, shorts, or joggers
jazz shoes or barefoot

Creative Movement/Tap & Ballet/Tap Classes

tap shoes
ballet shoes (please tuck in elastic ties)
dark solid leotard
pink tights

FOR GYMNASTICS & TUMBLING

Must have clean, barefoot or wearing a gymnastics shoe
Break the Barriers appropriate shorts, sweats, and fitted t-shirts are best for boys
Break the Barriers appropriate unitards, biker shorts, tank shirts or fitted t-shirts are best for girls
Sweatpants okay during winter months

FOR MARTIAL ARTS

Clean bare feet are required
Martial Arts uniforms are required by the first belt test
First time students can wear loose fitting sweatpants and a t-shirt

*More dress code information can be found on our website

Department Areas

NO FOOD in the facility
No latex balloons or other latex items in the facility
No horseplay in any area of the facility. No running! No fighting! No ball throwing!
No Heelys!
Non-students MUST be supervised by an adult at all times and NEVER LEFT UNATTENDED at Break the Barriers
Non-students are not allowed in the activity areas. All apparatus are OFF LIMITS to non-students. Please help us provide a safe environment.
Please notify BTB staff immediately if an injury occurs.
Parents are allowed in activity areas to assist the instructors in helping their children feel more comfortable with a completed liability release.
We welcome children with various needs. To keep our classes running smoothly, as a parent you may be asked to come out on the activity area to assist instructors. We want this to be the best experience for everyone! Scholarship applications are available in the office.

Additional Information

How did you hear about Break the Barriers?*

What program/class are you interested in registering your child for? (e.g. Gymnastics on Mondays at 4pm)*

Optional Grant Survey

How many people live in your household?

Is this a single parent household?

Yes

Is there disability in the household?

Yes

Family Income

Together we can break many barriers!

Please feel free to call us at any time if you have questions (559) 432-6292

Office Hours:

Monday – Thursday 8:30am – 7:15pm

Friday 8:30am – 6:15pm

Saturday 8:30am – 12:15pm

Phones go off one half hour before the office closes