Name:

D.O.B.         Age: 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26    Sex: Female Male

Address:

City:   State:   Zip Code:

Parent or Guardian Names:

Day Phone:   Evening Phone: 

Email:

Please include your email address so we can send you an email confirming we received this form.

Years of Training in:

                    Ballet

                    Pointe 

                    Modern 

                    Jazz 

                    Tap

Please Register Me For:

        Week 1 (July 24 - July 29)       $275

        Week 2 (July 31 - August 5)       $275

        Week 3 (Aug 7 - Aug 12)           $275

I need housing while attending Peoria Ballet Summer Intensives (at a cost of $250 a week).

I am a Peoria Ballet Academy Student.

Registration form and $25 nonrefundable registration fee are due ASAP.

The first half of your tuition is due by June 1, 2006 and the second half is due the first day of classes. Tuition and registration fee can be paid by credit card or check, made payable to Peoria Ballet.

Comments:

Total Amount Owed =       Tuition per Week ($275)

                                                            Housing per week ($250)

                                                            Registration Fee ($25)

Payment Information

Pay by Credit Card

        Total Amount $

        Please Call in Card Information

Pay by Check

        Total Amount  $

         *Send checks to Peoria Ballet Academy - 8800 N. Industrial Rd - Peoria, IL 61615

       

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