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Please complete one application per child.
The contact name must match the billing name, and the emergency contact must be someone other than the parental guardian in the event we cannot reach either parent.
If your child is currently enrolled at CPYB or your child has participated in a previous Dance Me A Story program, please login to your Family Portal using the red link above BEFORE completing this registration. Once logged in, it will reopen after a few moments in your existing account for you to complete.
For assistance, please contact the CPYB Department of Admissions & Student Affairs at 717.601.2840.
Dance Me A Story is for children ages 3 to 7. Children must be potty trained.
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Family Information |
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Students entered below will be added to your family's account
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Add New Student #1:
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Add New Student #2:
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Add New Student #3:
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Add New Student #4:
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Add New Student #5:
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Questions/Options: |
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1. How did you hear about Dance Me A Story? (CPYB.org, Facebook, brochure, mailing, referral, dance teacher, other)* | |
2. Does your student have food allergies? If YES, please detail in question 2A.* | |
**2A. Please detail your child's food allergy (type, severity, action to be taken in the event of a reaction, etc.) | |
3. Please enter your health insurance carrier. Include the policy holder name, policy number, carrier's address, and carrier's phone number.* | |
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Additional Information: |
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DANCE ME A STORY PAYMENT
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I understand that I will be charged $200 tuition within 5 business days after the submission of this form. Tuition includes one child's ticket to CPYB 2020/2021 spring production.
I've read the above and agree.
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DANCE ME A STORY SCHEDULE
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I understand that the camp is held at Carlisle Arts Learning Center (CALC) on Monday, June 8 and at the CPYB Warehouse Studios Tuesday, June 9 - Friday, June 12
I've read the above and agree.
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DECLINED TRANSACTION FEES
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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.
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REFUND POLICY
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I understand that the Dance Me A Story Camp $200 tuition is non-refundable and non-transferable.
I've read the above and agree.
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PUBLICITY RELEASE
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I hereby authorize Central Pennsylvania Youth Ballet (CPYB) to record the student's picture and voice on photographs, films, and tapes, to edit these recordings at its discretion, and to incorporate these recordings into movie and sound films on tapes, radio, or television broadcast programs. I also give my permission for CPYB to use and license others to use these materials in any manner or media whatsoever. CPYB is permitted to use these materials for publicity, advertising and sales promotion and to use the student's name, likeness and voice and biographic or other information in connection with them. I acknowledge that no promises of compensation were made by CPYB for such use. If I do not agree with the above, I must state so in the comment section below.
I've read the above and agree.
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FINANCIALLY RESPONSIBLE PARTY
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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.
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Other Questions/Comments: |
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Credit Card Verification: |
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Card Number: * |
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Name as it appears on card: * |
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Nickname:
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Card Expiration Month: * |
Exp Year: *
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Address Line 1:
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Address Line 2:
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City:
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State:
Zip:*
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