Registration
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The following information must be completed for EACH student enrolled in the CPYB 2018 August Course Program.
Please complete one questionnaire per student.
In addition to this questionnaire, the signed Physician Evaluation (PE) Form and a copy of the front and back of the student's insurance card are required. Please visit https://cpyb.org/school/summer-program/august-course to download the PE Form and to view instructions for uploading to our DropBox.
Please note:
The completed Health Form Package is valid through August 31, 2018. Students who completed this Health Form Package for the 2018 5-Week Summer Ballet Program do not need to re-submit.
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
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- denotes required fields
Family Information
First Name:
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Last Name:
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Type
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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:
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(Emails are kept confidential)
Address:
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City:
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State:
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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:
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Emergency Contact (Include name, address, phone number, e-mail)
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Students entered below will be added to your family's account
Add New Student #1:
(Show-Hide Details)
Student's First Name:
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Last Name:
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Student Gender:
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Female
Male
Birth Date:
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(format=mm/dd/yyyy)
Student Email:
Academic School District:
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Physical Limitations:
Allergies (If none, enter N/A):
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Medications (Leave blank if NONE):
Date of Most Recent Physical:
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Previous Ballet Training?:
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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:
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Previous Ballet Training?:
*
Previous Ballet Training cont.:
Questions/Options:
Please enter your student's last name.
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Please enter your student's date of birth (mm/dd/yyyy).
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Questions 1 - 17 below pertain to your student's medical history.
(checked=yes)
1. Does your student have any known DRUG allergies?
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Yes
No
1a. If you answered YES to the above question, please list drug allergies (e.g. penicillin, latex, etc.)
2. Does your student have any known FOOD allergies?
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Yes
No
2a. If you answered YES to the above question, please list food allergies.
3. Does your student have any OTHER allergies?
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Yes
No
3a. If you answered YES to the above question, please list other allergies.
4. Any recent or past Serious Accidents or Injuries that you feel we should know about? If none, please enter N/A.
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5. Any recent or past Surgeries that you feel we should know about? If none, please enter N/A.
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6. Any current diagnosis or history of Asthma, Bronchitis, Bronchiolitis, Pneumonia or Croup? If none, please enter N/A.
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7. Any current diagnosis or history of Heart Problems or Murmur? If none, please enter N/A.
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8. Any Eye Conditions? Include if your student wears corrective lenses. If none, please enter N/A.
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9. Any Problems with Ears or Hearing? If none, please enter N/A.
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10. Any Chronic or Recurrent Skin Problems? If none, please enter N/A.
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11. Any current diagnosis or history of Anemia or Bleeding Problems? If none, please enter N/A.
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12. Any current diagnosis or history of Seizures, Developmental Delays, ADD/ADHD, Autism Spectrum Disorder, or Other Neurological Issues? If none, please enter N/A.
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13. Any Mental Health Concerns that you feel we should be aware of? If none, please enter N/A.
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14. Any current or past Orthopedic Problems? If none, please enter N/A.*
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15. Any current diagnosis or history of Diabetes, Thyroid Disease , or Endocrine Problems? If none, please enter N/A.*
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16. Any history of Substance Abuse? If none, please enter N/A.*
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17. Any other information regarding your student's health that you feel we should be aware of and have not asked? If YES, please explain in the Additional Comments section at the end.
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Yes
No
Questions 18-19 are to identify medication(s) your student is instructed to use. Include prescription and over-the-counter medications. If none, please enter N/A.
(checked=yes)
REQUIRED FOR EACH MEDICATION: name of medication, dosage, method of administration (e.g., oral, topical, injection), frequency/time to be administered.
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18. Prescription Medication 1
18. Prescription Medication 2
18. Prescription Medication 3 (**If more than 3, please email additional prescription medication details to info@cpyb.org)
19. Over-The-Counter Medication 1
19. Over-The-Counter Medication 2
19. Over-The-Counter Medication 3 (**If more than 3, please email additional prescription medication details to info@cpyb.org)
Questions 20- 22 are to further assist us in caring for your student during the program.
(checked=yes)
20. Primary Language Spoken.
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21. Does the student live with both the parents in the same house?
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Yes
No
21a. If you answered NO to the above question, who does the student live with primarily?
21b. What is the visitation status of the non-custodial parent?
22. Has your student been out of the United States within the last 6 months? If YES, please list where.
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Does your student have health insurance coverage? *Copies of the front and back of your insurance card should be uploaded to our Dropbox.
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Yes
No
With my electronic signature, I attest that all information provided is true and correct to the best of my knowledge.
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After completion of this form, scroll back to the top and click ENROLL.
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Additional Information:
PRESCRIPTION MEDICATIONS
(Show-Hide Details)
It is the responsibility of the student and the student's parent(s) or guardian(s) to inform CPYB that the student has a prescribed inhaler, EpiPen, other prescribed medication.
Question 18 has been completed in full with the following information (if applicable):
- The drug name.
- The prescribed dosage.
- The method of administration (e.g., oral, topical, injection).
- The time(s) to be self-administered by the student.
- Medications must be in their original container and clearly labeled.
I've read the above and agree.
NON -PRESCRIPTION/OVER-THE-COUNTER
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It is the responsibility of the student and the student's parent(s) or guardian(s) to inform CPYB that the student is in possession of over-the-counter medication.
Question 19 has been completed in full with the following information (if applicable):
- The drug name.
- The prescribed dosage.
- The method of administration (e.g., oral, topical, injection).
- The time(s) to be self-administered by the student.
- Medications must be in their original container and clearly labeled.
I've read the above and agree.
SELF-POSSESSION/ADMINISTRATION POLICY
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All medications must be kept in possession of the student for whom it is prescribed. All medication administration will be the responsibility of the student for whom it is prescribed. Over-the-counter medications that a student may need during the August Course program will be the responsibility of each individual student. Students who require routine daily medication must be determined responsible enough by their parents to perform this task on their own without supervision. You agree that He/she has been instructed in, and understands, the purpose and appropriate method, frequency, dosage, and use of the medication. Under no circumstances should students share their medication with other students.
The staff and/or faculty of CPYB will not maintain possession or administer medication for any student at any time, nor will they supervise any student take medication.
I've read the above and agree.
CARE PLAN OF ACTION/PERMISSION FOR CPYB TO PROVIDE CARE
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By agreeing to the following, I permit Central Pennsylvania Youth Ballet to provide necessary assessment, treatment, and/or emergency care during any CPYB summer program my student is involved in.
I hereby give permission to the medical and health personnel selected by the Central Pennsylvania Youth Ballet (including but not limited to physical therapists, trainers, CPYB health staff, residential staff, urgent care facilities, emergency room staff and any consultants that they may deem necessary) to provide assessment, treatment, appropriate diagnostic testing or hospitalization for my child; to release any records necessary for insurance purposes and to provide necessary transportation for health care services.
I agree to assume all financial responsibility for medical costs incurred by the student, including, but not limited to, the medical and health personnel described above. It is the responsibility of students and their parents to determine whether their insurance will cover any or all services recommended or provided during their participation in the CPYB Summer Program.
I've read the above and agree.
PERMISSION TO CONTACT PHYSICIAN
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I give permission for CPYB to contact my child's medical provider listed on the Physician Evaluation (PE) Form for the purpose of confirming medical conditions/treatments or obtaining additional information in order to provide appropriate care. I agree to the best of my knowledge this health history is correct and complete. A photocopy of this PE form shall serve in the same capacity as the original document.
I've read the above and agree.
WAIVER OF LIABILITY
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You, the undersigned, hereby release Central Pennsylvania Youth Ballet and its employees of any and all liability which may, in any way whatsoever, arise out of, be related to, or be connected with this student's possession and/or self-administration of his/her medication. This is a complete and irrevocable release and waiver of liability.
You agree to indemnify and hold the Central Pennsylvania Youth Ballet and its employees harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney's fees, brought as a result of this student's possession and/or self-administration of his/her medication and to reimburse the Central Pennsylvania Youth Ballet for any such expenses incurred.
I've read the above and agree.
Enter your Full Name:
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Other Questions/Comments:
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