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. Under the student information, please enter "N/A" where applicable.
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.:
Additional Information:
PAYMENT
(Show-Hide Details)
I understand that I will be charged $60 within 5 business days after the submission of this form. Payment is non-refundable.
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 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.
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:
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