2024 Summer Intensive Registration Application All fees are due by May 1st To contact our Registrar, Lara Ciganko: registrar@cecchettiusa.org Classical Ballet Intensive Registration Application Date mm/dd/yyyy* MM slash DD slash YYYY Name* First Last Age* If participant is under 21 years, please enter age. It the participant is over 21 years, you may enter age or (Adult),if preferred. Participant Date of Birth* Registered As:* Student Dancer Adult Dancer Teacher Chaperone Guest Faculty Gender* Male Female Other Do you wish to reside on campus? Yes, I wish to reside on campus No, I do not wish to reside on campus Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Student's Sponsoring Teacher Level of Last Cecchetti Exam Passed, if Applicable Level at Which You Would Like to Participate* Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Diploma TC1 TC2 Associate Licentiate Fellow None of the Above Emergency Contact #1 Name* Relationship* Emergency Contact #1 Phone*Emergency Contact #1 Email* Emergency Contact #2 Name Relationship Emergency Contact #2 PhoneEmergency Contact #2 Email Medical Insurance Company* ALL participants must provide CUSA with a photocopy of both the FRONT and BACK of the medical insurance card. Please scan and email to Registrar, Lara Ciganko, at: registrar@cecchettiusa.org or, upload below. Group/Policy Number* Please indicate allergies, injuries, medical problems or special needs Roommate Request-NOT Guaranteed FREE T-Shirt Size* Youth Medium-6-8 Youth Large-10-12 Youth Extra-Large-14-16 Adult Small Adult Medium Adult Large Adult Extra Large Adult 2XL Terms and Conditions* I Agree Cecchetti USA reserves the right to alter the advertised program and faculty as necessary. Cancellations after July 1, will receive an 80% refund on tuition only. Room and board is non-refundable. Cecchetti USA shall have the right to use the name, photograph, video or other likenesses of all participants and to exhibit the same through any medium whatsoever for advertising, promotional or commercial purposes. All such reproductions shall be the exclusive property of Cecchetti USA. Cecchetti USA reserves the right to exclude or refuse any person at any time prior to or during the program if that person is incompatible with the general enjoyment and well being of ht event. In this instance, no refund will be given. The undersigned certifies that she/he is the parent and/or legal guardian of the minor child designated below and grants permission for the said minor child to participate in the Cecchetti USA Residential Summer Course at the facilities of the University of Maryland, College Park. Further, the undersigned for self and/or minor child agrees to hold harmless Cecchetti USA and the University of Maryland, College Park for any injuries or illness that may result from said participation or transportation associated herewith. The undersigned further authorizes a representative of the Cecchetti USA Residential Summer Course to obtain any medical treatment they deem necessary for self and/or minor child.Name of Parent of Minor Child or Adult Attending Course First Last Insurance Card Upload Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB, Max. files: 2. Δ
