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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:[email protected]
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
