Central Pennsylvania Youth Ballet Online Registration

Registration

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Registration for students *NEW* to a CPYB program. If your child previously attended a CPYB program, please contact us at info@cpyb.org if you need assistance.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact (Include name, address, phone number, e-mail)*

Health Insurance Carrier, Policy Holder Name and Policy Number*

Contact #1

(Billing Contact/Account Holder) First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work # *

Cell # *

By providing your phone number and checking this box, you agree to receive transactional and informational SMS messages from Central Pennsylvania Youth Ballet. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out and HELP for help.

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

(Optional Contact) First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #* By providing your phone number and checking this box, you agree to receive transactional and informational SMS messages from Central Pennsylvania Youth Ballet. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out and HELP for help.

Additional Info

Student Email

Academic School District*

Physical Limitations or Special Needs

Injuries (current or most recent)

Allergies (If none, enter N/A)*

Medications (Leave blank if NONE)

Date of Most Recent Physical*

After clicking on SELECT CLASS*, press SEARCH. On the pop-up screen make your selection based on the instructions in your acceptance email.

It is important that you select the correct class(es)!

- Please refer to the Confirmation or Enrollment Guide provided in an acceptance email or posted on CPYB.org.

- If you are unsure, please contact us at info@cpyb.org or 717.601.2840 before proceeding.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Academic School District*

Physical Limitations or Special Needs

Injuries (current or most recent)

Allergies (If none, enter N/A)*

Medications (Leave blank if NONE)

Date of Most Recent Physical*

After clicking on SELECT CLASS*, press SEARCH. On the pop-up screen make your selection based on the instructions in your acceptance email.

It is important that you select the correct class(es)!

- Please refer to the Confirmation or Enrollment Guide provided in an acceptance email or posted on CPYB.org.

- If you are unsure, please contact us at info@cpyb.org or 717.601.2840 before proceeding.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Academic School District*

Physical Limitations or Special Needs

Injuries (current or most recent)

Allergies (If none, enter N/A)*

Medications (Leave blank if NONE)

Date of Most Recent Physical*

After clicking on SELECT CLASS*, press SEARCH. On the pop-up screen make your selection based on the instructions in your acceptance email.

It is important that you select the correct class(es)!

- Please refer to the Confirmation or Enrollment Guide provided in an acceptance email or posted on CPYB.org.

- If you are unsure, please contact us at info@cpyb.org or 717.601.2840 before proceeding.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Academic School District*

Physical Limitations or Special Needs

Injuries (current or most recent)

Allergies (If none, enter N/A)*

Medications (Leave blank if NONE)

Date of Most Recent Physical*

After clicking on SELECT CLASS*, press SEARCH. On the pop-up screen make your selection based on the instructions in your acceptance email.

It is important that you select the correct class(es)!

- Please refer to the Confirmation or Enrollment Guide provided in an acceptance email or posted on CPYB.org.

- If you are unsure, please contact us at info@cpyb.org or 717.601.2840 before proceeding.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

Academic School District*

Physical Limitations or Special Needs

Injuries (current or most recent)

Allergies (If none, enter N/A)*

Medications (Leave blank if NONE)

Date of Most Recent Physical*

After clicking on SELECT CLASS*, press SEARCH. On the pop-up screen make your selection based on the instructions in your acceptance email.

It is important that you select the correct class(es)!

- Please refer to the Confirmation or Enrollment Guide provided in an acceptance email or posted on CPYB.org.

- If you are unsure, please contact us at info@cpyb.org or 717.601.2840 before proceeding.

Enroll in Classes

Select Class *

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Please fill out ONE of the following Payment Methods

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Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Required Policies

(Show-Hide Details)