PA Cyber Prom 2024 Registration

PA Cyber Prom 2024 Registration

Step 1: Prom Registration Form
Select which Prom you will be attending from the dropdown menu below:*
PA Cyber Student Name*

First NameLast Name
Grade Level*
Student ID*
Academic Advisor
Home Address*
City / State / Zip Code*
Home Phone

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Student Email Address*
example@mypacyber.org
Please Indicate if there are any special health needs or dietary restrictions:
If you are attending Prom with another PA Cyber student, please list the name of the PA Cyber student and do NOT include them in your total attending.
Total Number of People Attending (include yourself and non- PA Cyber guest in your total)*

Step 2: Guest Information (Non-PA Cyber Students Only)
For non-PA Cyber guests only!

** ALL NON-PA CYBER STUDENTS MUST COMPLETE DOWNLOADABLE FORM AND RETURN TO:
MAIL

Prom Committee
1200 Midland Avenue
Midland, PA 15059

- OR-

SCAN AND EMAIL
promcommittee@pacyber.org
How Many NON PA CYBER Prom Guests will be Attending?*
Prom Guest *

First NameLast Name
Download the Prom Guest Registration Contract by clicking here

Step 3: Behavior Contract
By signing this form we agree that we have read the attached rules and conduct expectations of the PA Cyber 2024 Prom and will abide by them. We understand the consequences for any inappropriate behavior. We understand that the dance is a school event and like all school events is WEAPONS, TOBACCO, DRUG, AND ALCOHOL FREE. Smoking, drinking and drug use will not be tolerated.
Student Signature*

Clear
Student's Phone Number:*

Area CodePhone Number

Step 4: Parental Consent Form
*I fully understand that participants are to abide by all rules and regulations governing conduct during the trip per student handbook and specific instructions of this trip.

*I agree that any cost for medical care for my student for illness or accident is my own responsibility. I understand that certain expenses for medical care may be covered by PA Cyber’s Accident coverage. I authorize PA Cyber to bill me for reimbursement of any expenses for medical care for my student that are paid for by PA Cyber during the event.

*I understand that I hold PA Cyber, its officers, agents, and employees, harmless from any and all liability or claims which may arise out of or in connection with my student’s participation in this activity.

*Please be aware that photos may be taken at any time during the activity by staff of PA Cyber. If you do not wish to have your child’s picture taken please mention that to the photographer at the time of the picture. Due to the number of attendees, it may occur that your child appears in the background of a photo, unfortunately this action cannot be prevented.

*All Reservations become Non-Refundable 1 week prior to scheduled event*

*PA Cyber reserves the right to cancel any reservation where payment has not been received by the payment due date for the activity.
I UNDERSTAND THAT I MAY BE CALLED IF MY CHILD OR THE GUEST OF MY CHILD HAS A PROBLEM AT THIS EVENT. THE PHONE NUMBERS WHERE I CAN BE REACHED ARE:
Home Phone Number*

Area CodePhone Number
Parent / Guardian Mobile Number*

Area CodePhone Number
Parent / Guardian Signature*

Clear
Date:

MonthDayYear
Relationship to Student:

Step 5: Make Payment
Privacy Policy

We are the sole owners of the information collected on this online registration form. We will not share your information with any third party outside of our organization, other than as necessary to fulfill your request.

Refund Policy

All Reservations become Non-Refundable 1 week prior to scheduled event*

*PA Cyber reserves the right to cancel any reservation where payment has not been received by the payment due date for the activity. *Please note: Bank Fees will be deducted from all REFUNDS processed online.
Select Payment Option*

I will pay online with credit or debit cardI will pay with check or money orderMy date is purchasing my prom ticket

Credit Card Payment*

USDENTER TOTAL AMOUNT HERE FOR PROM 2022

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

**** THIS SECTION IS FOR PACYBER PROM COMMITTEE ONLY ****
Mailed Payment Status:
Should be Empty:

PA Cyber Prom 2024 Registration

For non-PA Cyber guests only!