Registration
Dance Me A Story is for children ages 3 to 6. Students will experience a week of art, dance, and storytelling in an environment that will nurture their love for dance and make believe! This one -week camp is June 12-16, 2017 from 9 a.m. to 12 p.m. Visit CPYB.org for location and dress code information.

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.

In the student information section, please be sure to include any food allergies.

Event:
Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Type*
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
 
Questions/Options:
How did you hear about Dance Me A Story? (CPYB.org, Facebook, brochure, mailing, referral, dance teacher, other)*
Please enter your health insurance carrier. Include the policy holder name, policy number, carrier's address, and carrier's phone number.*
 
Additional Information:
 
DANCE ME A STORY PAYMENT
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I've read the above and agree.
 
DECLINED TRANSACTION FEES
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REFUND POLICY
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PUBLICITY RELEASE
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FINANCIALLY RESPONSIBLE PARTY
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Enter your Full Name: *   
 
Other Questions/Comments:
 
Credit Card Verification:
   
Card Number: *  
Name as it appears on card: *
Nickname:
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*