Perichild Program Application Form

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

The School at Peridance

How to Apply

You may apply on-line and submit payment via credit card using our on-line secure application form below. If you prefer, you may download and print the Adobe Acrobat version of the application form (requires Adobe Acrobat Reader), fill it out and either fax it with your credit card information or mail it with a check or money order for the registration fee.

Application Form

Spring Session 2012

Registration Options: * Required Information For 4 or more Multiple classes, Please Contact Shelley (212) 505-0886.

		When specifying classes, enter the class name and the day time and date it is held.
First Student's Full Name:	*	Class:

Age:		Note: If you are not enrolling a second student, but are enrolling a single student in two classes, complete both class entries and leave the second student information blank.

Birth Date:

2nd Student's Full Name:		Class:
Age:

Birth Date:

PERSONAL INFORMATION

Parent's Name: * Required Information

Address1:

Address2:

City:

State: Zip:

Work Phone:

Home Phone: * Required Information

E-Mail: * Required Information

Person Accompanying Child:
Day Time School:

Specific problems we might need to know about:

How did you hear about us (New Students):

I, the Minor's parent and/ or legal guardian, understand the nature of the Activities and the Minor's experience and capabilities and believe the Minor to be qualified, in good health, and in proper physical condition to participate in the Activities.I understand that dance training comes with a risk of injury and hereby waive responsibility from and hold harmless Peridance Capezio Center, it's employees, teachers and affiliated staff for any injuries, losses, or personal property damage in the Minor's account derived from the participation in any class, audition, workshop, rehearsal, or other activity conducted on the premises. By submitting this form, I also give consent for my child to be photographed during School at Peridance activities. These photos are for the sole use of Peridance for promotion and display and not for any commercial purpose.

In checking this box, I fully understand and agree to the terms above. * Required

I authorize Peridance Capezio Center to charge my credit card with the following amount.

CREDIT CARD INFORMATION

Credit Card:

Name on Card: * Required Information

Card Number: * Required Information

CIV Code: What is this? * Required Information

Expiration Date: * Required Information

DONATION FORM

Peridance Contemporary Dance Company (PCDC) and the Peridance Youth Ensemble are not-for-profit companies.
I'd like to support their artistic endeavors!!

Please charge my Credit Card with the additional amount indicated below:

Choose Your Donation Amount, and with Your Tax-Deductible Donation you will receive:

I do not wish to make a donation at this time.

$50 - A Peridance Capezio Center T-Shirt

$100 - 2 tickets to your child’s Spring 2012 Concert

$250 - 2 tickets to a PCDC performance at the Salvatore Capezio Theater

$500 - Peridance Capezio Center T-Shirt
2 tickets to your child’s Spring 2012 Concert
2 tickets to a PCDC performance at the Salvatore Capezio Theater
$75 - tuition discount for The School at Peridance 2012 Spring Session

$750 - Peridance Capezio Center T-Shirt
2 tickets to your child’s Spring 2012 Concert
2 tickets to a PCDC performance at the Salvatore Capezio Theater
$150 tuition discount for The School at Peridance 2012 Spring Session

For Donations of more than $750, please visit our Donations Page.

WE THANK YOU FOR YOUR SUPPORT!

Important: By submitting this registration form, you authorize Peridance Capezio Center to charge your credit card for the specified amount and register your child or children in the requested classes. In the event that we are unable to complete the registration, due to full classes, incorrect or incomplete information, etc., we will notify you and will not charge your card or complete registration until the appropriate corrections are made. By submitting this form, you also give consent for your child to be photographed during School at Peridance activities. These photos are for the sole use of Peridance for promotion and display and not for any commercial purpose. There are no refunds once registrations are processed and paid.