Certificate Program Application Form

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126 East 13th Street
New York, NY 10003
U.S.A
212.505.0886
info@peridance.com

Certificate Program Registration form

New Student Current Peridance Student

Personal Information

First Name:	* Required Information
Last Name:	* Required Information
Address:
City:
State:
Zip code:
Date of Birth:	* Required Information
Phone Number:	* Required Information
Email:	* Required Information
Gender:	Female Male

Additional Information I am interested in joining the: Ballet/Contemporary Track
Commercial Track
I would like to audition by:
Attend a Public Audition
Washington DC: November 26th, 2011, 1:00-2:30 PM
New York @ Peridance Capezio Center: Tuesday, January 3rd, 2012, 5:30-7:00 PM
Amsterdam, The Netherlands: February 11th, 2012, 11:00-12:30 PM
Milan, Italy: February 13th, 2012, 11:30-1:00 PM
Torino, Italy: February 14th, 2012, 3:00-4:30 PM
Rome, Italy: February 15th, 2012, 9:00-10:30 AM
Rome, Italy: February 15th, 2012, 12:00-1:30 PM
Naples, Italy: February 16th, 2012, 3:30-5:00 PM
Chicago: February 25th, 2012, 11:30-1:00 PM
New York @ Peridance Capezio Center: Sunday, March 4th, 2012, 2:30-4:00 PM
Miami: March 24th, 2012, 1:00-2:30 PM
New York @ Peridance Capezio Center: Sunday, April 15th, 2012, 2:30-4:00 PM

Arrange an Audition with the Certificate Program Coordinator

By DVD/Video Link Submission

CP SCHOLARSHIP AUDITION, New York @ Peridance Capezio Center: Sunday, June 17th, 2012, 4:00 - 6:00 PM

I would like to begin the Certificate Program this: Fall (September 4th, 2012)
Spring (January 28th, 2013)

I would also like to take the Summer Session:
(July/August)
* Required for International Students.

Citizenship: I am a US Citizen/Permanent Resident I am NOT a US Citizen/Permanent Resident
If NOT US, Country of Residence:
How did you hear about Peridance's Certificate Program?
I would like information about housing

Important!Application Fee, $25 (non-refundable).
If you are unable to pay online please contact us at: 212-505-0886

Credit Card Information

Credit Card:	* Required Information
Name on Card:	* Required Information
Card Number:	* Required Information
CIV Code: What is this?	* Required Information
Expiration Date:	/ * Required Information (mm/yy)

In order to prevent spam please type the two words you see above.

If you have are having difficulty submitting this form or have questions, please call us at 212-505-0886 or e-mail us at certificateprogram@peridance.com.

Important!Application Fee, $25 (non-refundable). If you are unable to pay online please contact us at: 212-505-0886

If you have are having difficulty submitting this form or have questions, please call us at 212-505-0886 or e-mail us at certificateprogram@peridance.com.

Important!Application Fee, $25 (non-refundable).
If you are unable to pay online please contact us at: 212-505-0886