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1 General Information


Winter Intensive Registration Packet


General Information

Are you under the age of 18?
For applicants below 18 years, a Parent/ Guardian will be required.
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Cell Phone
phone
First Name
Last Name
Age
Birthday
date_range
Are you a U.S. Citizen / Resident?
Cell Phone
phone
Social Media
computer
AddressBuilding no., Street
Apt #
City, State/Province
Postal / Zip Code
How did you hear about us?

Emergency Contact

Primary Emergency Contact (Must be Parent or Legal Guardian if participant is under the age of 18)

Name
Relationship to Participant
U.S AddressBuilding No., Street, City, State (Province), Country
Apt #
Postal / Zip Code
Cell Phone
phone
Home Phone
phone
Work Phone
phone

Secondary Emergency Contact (Other than a Parent or Legal Guardian)

Name
Relationship to Participant
U.S AddressBuilding No., Street, City, State (Province), Country
Postal / Zip Code
Apt #
Cell Phone
phone
Work Phone
phone
Home Phone
phone

Waiver/ Release/ Policy

Please carefully read the Liability Waiver, Media Release and Refund/Cancellation Policy below and sign. If you are under 18, your parent or legal guardian must sign as well. 

Liability Waiver

I am participating in Peridance’s Winter Intensive and understand that dance training comes with a risk of injury. I also understand I cannot hold Peridance Capezio Center or any member of its staff liable for any injuries that may occur as a direct result of participating in dance classes, rehearsals, seminars, activities, etc. 

Media Release

I hereby give my consent to Peridance Capezio Center to use my name and any form of dance-related media acquired during my study (video, photography, voice, etc.) for publication, advertising, marketing, promotional campaigns, etc. I understand that I will not be compensated by Peridance or a third party should Peridance decide to use these materials.

Refund/Cancellation Policy

Students may only receive a refund if he/she notifies Peridance Capezio Center at least 3 weeks prior to the beginning of the Intensive. If a refund is given, a $100 registration and processing fee will be deducted from the refund amount. Refund for payments made by Credit Card will bear an additional deduction of 3% (to cover credit card fees). There are no refunds once you have begun the program, and no refunds will be given for any absences not made up during your period of study. Peridance reserves the right to cancel the Winter Intensive if the enrollment is insufficient. In such case, student will receive a full refund.

Participant’s full name
Today's date
date_range
Participant’s SignatureI agree to the terms and conditions
(Sign Here)
Clear Signature
Parent/Legal Guardian's full name
Parent/Legal Guardian SignatureI agree to the terms and conditions
(Sign Here)
Clear Signature

Scholarship

Have you received a scholarship?
Which scholarship have you received?
When and Wheredid you receive it?
Copy of your scholarship award or letterupload
cloud_uploadUpload
Scholarship AgreementBy clinking this, you assert that you have read and hereby agree to the below terms.

Payment

Payment methods

Wire Transfer 

Payment should be paid in 3 days to secure your spot.

$15.00 transfer fee should be included.

Account Name: Peridance Center LLC 

Account No: 4984525413 

Bank Name: Citibank, N.A. 

Swift Code: CITI US 33 

Bank Address: 52 East 14th Street, New York, NY 10003-4140 USA 

Routing No: 0210-0008-9 

*Applicant name must be included in the memorandum for all wire transfers, or may be subject to delays.

Check or Cash

Payment should be paid in 3 days to secure your spot.

- All checks and money orders must be made out to “Peridance.” Include applicant full name in the memorandum.

- Send a check to Peridance Capezio Center Attn: Winter Intensive, 126 East 13th Street New York, NY 10003.

- Do not mail cash. Cash option for applicants that wish to pay in person while in the United States at the time of application.

$ [(field64*field62)+field64]
Stripe Card Placeholder
Apply

*By clicking Submit Form, you are agreeing to the Terms and Conditions


Contact us anytime with questions at applications@peridance.com or 212-505-0886.

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