Intensive Semester Registration form - Peridance Semester Registration...1. No refund will be given...

IntensiveSemesterApplicationPackageUpdated1/16/2017

INTENSIVE SEMESTER AT Peridance Capezio Center

Peridance Capezio Center

ü SemesterApplicationDeadline

(DomesticStudents)StartDate EndDate Vacation

Fall2017 August1st,2017 September1st,2017 February28th,2018 2week

Spring2018 December1st,2017 January2nd2018

June30th,2018

2week

Admission Application Package

FirstName LastName

MobilePhone Email

CurrentAddress Street Apartment/Unit Town/City

Province/State/Region Country Postal Code

Citizenship CountryofBirth

Gender☐Male☐Female DateofBirth(MM/DD/YYYY)

Howdidyouhearabouttheprogram(if‘friend’puthis/hername):

EmergencyContactName

MobilePhone Email

RelationshiptoApplicant Citizenship

Applicant Personal Information Prospective Students

Which course are you applying for?

Application Materials

Pleasereadthefollowingapplicationinstructionsthoroughlyandsubmitallapplicationmaterialswithcare.☐$50ApplicationFee(DomesticStudents)☐ $350ApplicationFee(InternationalStudents)☐ CompletedRegistrationForm☐ Headshot☐ Danceandworkresume☐ Shortdescription(upto500words)ofyourselfandwhatyouhopetoachievewithyourtraininganddancepursuitsAllnecessarydocumentsmustbesubmittedviae-mailto:intensivesemester@peridance.com

IntensiveSemesterApplicationPackageUpdated1/16/2017

INTENSIVE SEMESTER AT Peridance Capezio Center

Peridance Capezio Center

Haveyoupaidtheapplicationfee:$50(Domestic)/$350(International)onlinewithCreditCard? ☐ Yes☐ No(Ifno,pleaseprovideinformationbelow)Howdoyouwanttopayyourapplicationfeeandtuition?☐BankCheck,PersonalCheck,MoneyOrder*,orCash**

*Allchecksandmoneyordersmustbemadeoutto“Peridance.”Includeapplicantfullnameinthememorandum.**Donotmailcash.CashoptionforapplicantsthatwishtopayinpersonwhileintheUnitedStatesatthetimeofapplication

☐CreditCard(Peridanceacceptsthefollowingmajorcreditcards.Circleone)

Visa/MasterCard/Discover/AmericanExpressNumber - - -

Exp.Date(MM/YY) SecurityCode NameonCard

AuthorizationSignature TotalAmountCharged$ USD

*Mustincludea3%transactionfeeforallcreditcardtransactionsover$1,000.00USD☐WireTransferTotalAmountBeingWired+$15.00wiretransferfee‡$ USD

AccountName: PeridanceCenterLLC AccountNo: 4984525413BankName: Citibank,N.A. SwiftCode: CITIUS33BankAddress: 52East14thStreet,NewYork,NY10003-4140USA RoutingNo: 0210-0008-9

*Applicantnamemustbeincludedinthememorandumforallwiretransfers,ormaybesubjecttodelays.

Payment Information

Refund Policy

I_______________________________________whostatesuponmyoathconsenttothefollowingrefundpolicy:Participant’sName

1. Norefundwillbegivenforparticipant’schoosingtowithdrawfromtheprogramafterthestart-dateformoneyspaid.

2. Shouldaparticipantchoosetowithdrawafterthestart-date,acreditwillbeaddedtotheaccounttobeusedforclassesintheOpenClassScheduleforuptotwelve(12)monthsfromthewithdrawaldate.

3. Theapplicationfeeoffiftydollars($50.00)isnon-refundablefee.

4. Inthecasearefundisdue,apaymentwillbemadebycheckONLYandwillbeaddressedtotheoriginalpartythat

madetheinitialpaymentminustenpercent(10%)processingfeeandotherfeesaccrued(shipping,creditcardetc.)

Participant’sName(PleasePRINT)SignatureDate

Parent/LegalGuardian(ifParticipantisunder18yearsofage)SignatureDate

IntensiveSemesterApplicationPackageUpdated1/16/2017

INTENSIVE SEMESTER AT Peridance Capezio Center

Peridance Capezio Center

• Student'sFullName: FirstName,LastName

• HowdidyouhearaboutIntensiveSemester?• Whatisyourleveloftraining?

☐ None☐ Beginner☐ Intermediate☐ Advanced☐ Professional

• Whichdisciplinewillyoubefocusingon?(PleasechooseONE)

☐ Ballet/Contemporary☐ Modern/Contemporary☐ Commercial/Urban☐ Jazz/Tap☐ Other• Doyoucurrentlystudydance? ☐ Yes ☐ No

Ifyes,where?• Pleaselistyourpreviousdancetrainingandperformanceexperiences:(includelength)

• Willyoubepursuingaprofessionalcareerindance? ☐ Yes ☐ No• Ifno,whatareyouplansforafuturecareer?

Liability Waiver and Media Release

PleasecarefullyreadtheLiabilityWaiverandMediareleasebelowandsign.Ifyouareunder18,yourparentorlegalguardianmustsignaswell.

LiabilityWaiver

IamparticipatinginPeridance’sIntensiveSemesterandunderstandthatdancetrainingcomeswithariskofinjury.IalsounderstandIcannotholdPeridanceCapezioCenteroranymemberofitsstaffliableforanyinjuriesthatmayoccurasadirectresultofparticipatingindanceclasses,rehearsals,seminars,activities,etc.

MediaRelease

I hereby givemy consent to Peridance Capezio Center to usemyname and any formof dance- relatedmedia acquiredduringmy study (video, photography, voice, etc.) for publication, advertising,marketing, promotional campaigns, etc. IunderstandthatIwillnotbecompensatedbyPeridanceorathirdpartyshouldPeridancedecidetousethesematerials.

Participant’sName(PleasePRINT)SignatureDate

Parent/LegalGuardian(ifParticipantisunder18yearsofage)SignatureDate

Quest ionnaire