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This form is for students participating in the Spring 2018 DiscoverDance Workshop.
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!
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.:
Questions/Options:
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:
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