Registration
Already a customer? Click here to login.
After reading the below summary, click ADD TO CART to complete form.
Complete this form to participate in optional supplemental classes offered during the 5WSBP.
These classes are offered at various times, typically in the early evening during the week and on Saturday afternoons.
The supplemental schedule will be available at the start of the program and may include hip hop, Pilates mat, stretch and yoga. Please take into consideration your rigorous ballet schedule as supplemental classes are typically scheduled in your free time.
A supplemental card for
10 classes is $140
and posted automatically to your family account. Supplemental cards can be purchased throughout the entire program.
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
*
Adult Student
Dickinson Student
Family approved contact
Father
Grandparent
Guardian
Host Family
Male Scholarship Program Applicant
Mother
Parent
RA for Summer Program
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Emergency Contact (Include name, address, phone number, e-mail)
*
Students entered below will be added to your family's account
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Academic School District:
*
Physical Limitations:
Allergies (If none, enter N/A):
*
Medications (Leave blank if NONE):
Date of Most Recent Physical:
*
Previous Ballet Training?:
*
Previous Ballet Training cont.:
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Academic School District:
*
Physical Limitations:
Allergies (If none, enter N/A):
*
Medications (Leave blank if NONE):
Date of Most Recent Physical:
*
Previous Ballet Training?:
*
Previous Ballet Training cont.:
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Academic School District:
*
Physical Limitations:
Allergies (If none, enter N/A):
*
Medications (Leave blank if NONE):
Date of Most Recent Physical:
*
Previous Ballet Training?:
*
Previous Ballet Training cont.:
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Academic School District:
*
Physical Limitations:
Allergies (If none, enter N/A):
*
Medications (Leave blank if NONE):
Date of Most Recent Physical:
*
Previous Ballet Training?:
*
Previous Ballet Training cont.:
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Academic School District:
*
Physical Limitations:
Allergies (If none, enter N/A):
*
Medications (Leave blank if NONE):
Date of Most Recent Physical:
*
Previous Ballet Training?:
*
Previous Ballet Training cont.:
Questions/Options:
I would like to purchase a 10-class card for supplemental classes offered during the 2018 5WSBP.
*
Yes
No
I understand that the non-refundable fee of $140 will be charged to the payment information in my Family Portal within 48 hours after submission of this form.
*
Yes
No
After completion of this form, scroll to the top and click ENROLL.
(checked=yes)
Additional Information:
SUPPLEMENTAL CLASSES
(Show-Hide Details)
1. I understand that supplemental class cards can only be purchased through the Family Portal.
2. I understand supplemental class cards purchased prior to the start of the program will be placed in the student registration packet.
3. I understand supplemental class cards purchased during the 5WSBP can be picked up at the front desk of the CPYB Warehouse Studios within 1 business day from the purchase.
4. I understand that supplemental cards must be used within the 5-Week Summer Ballet Program and are non-transferable to other CPYB programs.
I've read the above and agree.
FINANCIAL POLICIES
(Show-Hide Details)
1. I understand CPYB will post the value of the supplemental class card to the financial information in the Family Portal once this form is submitted.
2. I understand that it is my responsibility to notify the financial institution due to limits on my account or fraud prevention. I understand that transactions declined for any reason incur a $35 declined transaction fee. ONLY if a letter from the financial institution stating the account was closed due to fraud is provided within 48 hours prior to the payment being processed will the $35 declined transaction fee be waived. Please visit the tuition page on CPYB.org to access the Refund Policy.
3. I understand that all the fees posted and paid through the submission of this form are non-refundable and non-transferable to any student or other CPYB program.
I've read the above and agree.
FINANCIALLY RESPONSIBLE PARTY, CUSTODIAL PARENT, AND STUDENT
(Show-Hide Details)
My electronically typewritten signature below shall be legally binding and serve in the same capacity as my original penned signature.
I've read the above and agree.
Enter your Full Name:
*
Other Questions/Comments:
Please Wait...
