Registration
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Please complete the following registration form in its entirety. The contact name must match the billing name. Please submit ONE registration form per child.
Tour participants must be 11 years of age by the start of the 5-Week Summer Ballet Program (June 23, 2018).
This form is for
Philadelphia ONLY
.
If you already applied for the 2018 5-Week Summer Ballet Program,
do not
complete this registration form. Contact us at 717.245.1190 or info@cpyb.org.
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 or Special Needs:
Allergies (If none, enter N/A):
*
Medications (Leave blank if NONE):
Date of Most Recent Physical:
*
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 or Special Needs:
Allergies (If none, enter N/A):
*
Medications (Leave blank if NONE):
Date of Most Recent Physical:
*
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 or Special Needs:
Allergies (If none, enter N/A):
*
Medications (Leave blank if NONE):
Date of Most Recent Physical:
*
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 or Special Needs:
Allergies (If none, enter N/A):
*
Medications (Leave blank if NONE):
Date of Most Recent Physical:
*
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 or Special Needs:
Allergies (If none, enter N/A):
*
Medications (Leave blank if NONE):
Date of Most Recent Physical:
*
Questions/Options:
1. My student is a beginner with no dance experience. If YES, please do not complete this registration and contact CPYB at 717.245.1190.
*
Yes
No
2. Has the student attended the CPYB 5WSBP in previous years? If YES, answer 2A.
*
Yes
No
***2A. Please list the level and years attended in this text box.
3. Please provide student's most recent dance experience. Provide name of ballet school, street address, city and state.
*
4. Please provide the number of years the student has studied ballet.
*
Additional Information:
EVENT DETAILS
(Show-Hide Details)
I understand that participation in a #CPYBsummer Experience Tour event does not guarantee acceptance into the 5-Week Summer Ballet Program (5WSBP).
I further understand that an application for the 5WSBP must be completed in order to be considered for acceptance.
I've read the above and agree.
PAYMENT
(Show-Hide Details)
I understand that I will be charged $40 within 5 business days after the submission of this form. Payment is non-refundable.
I further understand that if I choose to complete an application for the 2018 5-Week Summer Ballet Program AFTER attending this #CPYBsummer Experience Tour, this fee will be credited toward the total application fee.
I've read the above and agree.
DECLINED TRANSACTION FEES
(Show-Hide Details)
I understand that it is my responsibility to notify the financial institution due to limits on my account or fraud prevention. I understand that transaction 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.
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:
Credit Card Verification:
*
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