Intersession 2020 Registration Only

Student Information
Full Name *

First Name Last Name
Local Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PSU Student? *

Yes No
Permanent Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Have you taken class at CPDW in the past?

New Student Returning Student
How did you learn about CPDW?
Why did you choose CPDW?
What do you hope to gain from your class experience?
Student E-mail *
Contact Number *

Area Code Phone Number
Age *

Child/under 18 Adult/over 18
Birthdate *

Month Day Year
Date
Grade
Parent/Guardian #1
Name *

First Name Last Name
Relationship
Email *
This email will receive a form submission confirmation
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian #2
Name

First Name Last Name
Relationship
Email
example@example.com
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian #1
Parent/Guardian #2
Emergency Contact *
Will you buy a class card?

Yes, a 5-class card. Yes, a 10-class card. Yes, a 15-class card. Yes, a 20-class card. No, I will pay per class.
Please let us know which class you intend to take, so that we may have your card ready.

Agreements
FINANCIAL/PAYMENTS POLICY: Class cards are non-refundable and non-transferable. Tuition credits do not apply. All classes must be paid for at the time they are taken. Three-student minimum for class session to be held. Schedule is subject to change.
RELEASE FROM LIABILITY: It is expressly agreed that all exercise, training dancing, participation in classes, and the use of facilities of the Central Pennsylvania Dance Workshop by students is undertaken at the sole risk of students or parents/guardians of minor students. Students and parents/guardians of minor students hereby agree to hold the Central Pennsylvania Dance Workshop harmless, releasing forever its employees, owners, operators, agents, servants, advisors, and assignees from any and all claims for injury and/or property damage.
PHOTO RELEASE: I give CPDW permission to use images of me or my child taken during CPDW activities in CPDW-related publications, including website and social media. I understand that CPDW will not identify individuals by name in any publications nor tag individuals on any social media.
Type a question

I grant permission I do not grant permission
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: