This form is for students participating in the Spring 2019 DiscoverDance Workshop. Deadline to complete is 11:59 PM December 10, 2018.

Please review the instructions in your DiscoverDance Letter to collect the information needed before enrolling your student in Central Pennsylvania Youth Ballet's DiscoverDance Program.

The contact fields pertain to the mother and/or father of the DiscoverDance student. For emergency information, DO NOT enter either parent's information. We ask that you provide a third-party contact in the event we cannot reach either parent.

Thank you!

Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
Address: *
City: * State: * Zip: *
Emergency Contact (Include name, address, phone number, e-mail)*
Students entered below will be added to your family's account
Please rank the following Groups based on your preference (1-2-3). We will do our best to accommodate and will discuss in further detail during the January 26 meeting.
Group A: Wednesday 4:30 - 5:45 PM | Saturday 9 - 10:30 AM*
Group B: Wednesday 5:45 - 7:00 PM | Saturday 10:30 AM - 12:00 PM*
Group C: Wednesday 7:00 - 8:15 PM | Saturday 12:00 - 1:30 PM*
Please enter your Health Insurance Carrier. Include the Policy Holder Name, Policy Number, Carrier's Address and Carrier's Phone Number.*
Additional Information:
Other Questions/Comments: