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    Certificate Program/Winter Intensive Registration Form

    New Student |  Current Peridance Student
    If Current student - Student Number

    Choose a Program:     Winter Intensive    

    Personal Information
    First Name:
    Last Name:
    CitizenshipI am a US Citizen/Permanent Resident
    I am NOT a US Citizen/Permanent Resident
    If NOT US, Country of Residence:
    Zip code:
    Phone Number:
    Date of Birth:
    Gender: Female Male
    Parent/Guardian Name (if under 18 years of age):
    Parent/Guardian Email (if under 18 years of age):
    Parent/Guardian Phone (if under 18 years of age):
    Where do you currently Dance?
    How did you hear about the program?
    Please give us a brief description of
    your goals and expectations from the Program:

    Certificate Program: Additional Information
    I am interested in joining the:   Ballet/Contemporary Track     Commercial Track

    Credit Card Information

    • Application Fee, $30 (non-refundable).
    • If you are unable to pay online, please contact us at: 212-505-0886 or email
    • Students living in the Tri-State area must attend audition in person. If you are unable to attend a public audition you may submit a DVD/Video link. Look for instructions on the program's information page.

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

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

    Peridance Partners

    Contact Us: 126 East 13th Street New York, NY 10003 U.S.A. | Tel: 212-505-0886 | Fax 212-674-2239 | Email:
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