Registration

	Student's First Name: *	Last Name: *
	Student Gender: *	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.:

	Student's First Name: *	Last Name: *
	Student Gender: *	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.:

	Student's First Name: *	Last Name: *
	Student Gender: *	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.:

	Student's First Name: *	Last Name: *
	Student Gender: *	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.:

	Student's First Name: *	Last Name: *
	Student Gender: *	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.:

I understand that applicants with previous training experience are required to submit three photos to documents@cpyb.org to complete their application materials. Until photos are submitted the student's application is incomplete and will not be considered.

I understand that upon submission of this application and the required photos, CPYB will approve or disapprove the application. All applicants will be notified of their status via e-mail.

I understand the submitted date of the application form determines my eligibility for program rates when selecting a payment option for dorm and non-dorm. The options are described in the application directions and on CPYB.org

I understand that in order to receive the February, March or April rate I must reserve my place in the 5WSBP by the 14th of my desired month by 11:59 pm. This transaction occurs through the submission of the "Reserve Your Place in the Program" form, following your acceptance into the program.

I understand cash is NOT accepted as a form of payment. All application fees MUST be via credit card through the Family Portal. CPYB accepts Visa, MasterCard and Discover.

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. Please visit the tuition page on CPYB.org to access the Refund Policy.

1. I have read and understand the Refund Policy as outlined on CPYB.org. I understand that there will be no exceptions to these refund policies.
2. I understand that all the fees posted and paid through the submission of this form are non-refundable and non-transferable to any student or other CPYB program.

I understand only students attending the entire 5WSBP can apply for scholarship assistance by the JANUARY 20 deadline. I understand that after January 20, 2017 the scholarship application option is no longer available. CPYB does not keep electronic tax information after the scholarship review process is completed. All documentation is permanently deleted.

My electronically typewritten signature below shall be legally binding and serve in the same capacity as my original penned signature.