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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!

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 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: