Application for 2016 Summer Dance IntensiveOut of Area Application

Please fill out application form completely and accurately. PRINT CLEARLY in Black or Blue Ink ONLY Application must include: Dance Headshot Photo (no costumes please) and First Arabesque Profile Photo (Ladies en pointe if applicable), • 10-minute or less Youtube Link or DVD Video must include: (1) one side only of each barre exercise (plies, tendus, adagio, grand battement); (2) center work (tendus, pirouettes, petit allegro, grand allegro); and (3) pointe work (if applicable, either at the barre or in the center) or a variation from the classical repertoire on pointe and non-refundable $200 tuition deposit. If the student is not accepted, the tuition deposit will be returned to you immediately. If the student is placed on the waiting list, it will be returned to you no later than June 1, 2016.

Applications received after June 1, 2016 may incur an additional $100 processing fee. Permission from Intensive Director must first be obtained before submitting application after June 1, 2016.

Name______________________________ Age on August 1, 2016 ________ Date of Birth_____________________ Height __________ Weight ___________ Phone (___)____________ If under 18, Parent or Guardian: _____________________________________________________________________

Parent Daytime/Cell Phone Number: (___) __________________

Address__________________________________________________________________________________________

City ____________________________________ State _____________________ Zip ____________________E-mail Address to which you want account statements sent: ___________________________________________ Years of Ballet Training Since Age 8 ________________________ Years on Pointe (if applicable)____________ T-Shirt Size: □ Child Small □ Child Medium □ Child Large □ Adult Small □ Adult Medium

□ Adult Large □ Adult Extra Large

If 18 or over, person responsible for payment of account: □ Student □Parent I Will Need Housing: □ Yes □ NoHow will you be arriving: □ Car □ Airplane Other: __________________ □ Undecided How did you hear about The Scripps Performing Arts Academy and the Intensive? □ Company performance □ Internet □ Friend □ Ballet school □ Pointe Magazine

I understand that students are expected to maintain the highest standards of conduct at all times. As a participant in the The Scripps Performing Arts Academy Summer Intensive, I will be willing to adhere to the guidelines and rules of the Intensive.

______________________________________________ Student’s Signature

_____________________________________________ Parent’s/Guardian’s Signature (If student is under 18)

SCRIPPS PERFORMING ARTS ACADEMY

Acceptance and Payment Information Students were accepted and placed based on ability and physical strength, not age.

The Pre-Professional Program is held at our Scripps Ranch location July 25-August 13 for students aged 11-19. The Pre-Professional program is divided into two or three levels, limited to 16-20 students per level.

The Intermediate Program is held at our Torrey Hills (for the firs two levels) and Scripps Ranch locations (for the last level) from August 1-13 for students aged 10-18. The Intermediate program is divided into three levels, limited to 12-16 students per level.

Acceptance Packets with Schedules and Required Items will be e-mailed home July 1, 2016.

Applications or payments received after June 26 may not be accepted.

Tuition for the Summer Intensive Ballet Programs includes all classes and a Summer Intensive T-Shirt.

Room and Board for students attending from out of the area is an additional $750 and is available for students accepted to the Pre-Professional Program Only.

3- Weeks Pre-Professional w/o Room & Board

3-Weeks Pre-Professionalw/Room & Board

2- Weeks Intermediate

w/o Room & BoardIf Postmarked on or Before March 31 $1275 $2025 $975

If Postmarked April 1- April 30 $1475 $2225 $1175If Postmarked May 1- June 3 $1675 $2425 $1375

*Two Week option is ONLY available for students accepted into the Intermediate Program. Pre-Professional Program students interested in the two week option should contact Miah Nwosu for details*

Please do not postdate checks. They are processed upon receipt. A fee of $35 is charged for returned checks.

Please Mail Payments on or before appropriate due dates to: The Scripps Performing Arts Academy Summer Intensive 9920 Scripps Lake Drive, Suite 105, San Diego, CA 92131

Registration may be paid by bank transfer, VISA or MasterCard by phone or online. Please call the office on or before appropriate due dates.

There are no refunds.

Date Application Mailed __________________________

Dear Teacher, _______________________________ has applied and been accepted to our 2016 Summer Dance Intensive. The enclosed recommendation form must be filled out and received by our office no later than June 30, 2016. Your answers to all questions will be confidential, so please be as honest as possible.

Sincerely, Miah NwosuIntensive DirectorThe Scripps Performing Arts Academy

Teacher Evaluation Form (Due June 30) Please type or print clearly. Student’s Name: _____________________________________________________________________________Teacher’s Name: _____________________________________________________________________________Teacher’s Phone: _____________________________________________________________________________How long have you been the student’s teacher? ___________________________________________________How many days per week does student take class? _________________ Hours per day? ___________________Specify type of dance (i.e. ballet, jazz, tap, etc.) _____________________________________________________Are any of these combination classes? Please explain. _______________________________________________Does student maintain consistent class attendance? □ Yes □ No If not, explain. _______________________________________________________________________________________________________________________What is student’s classroom attitude and relationship to other sudents?_____________________________________________________________________________________________________________________________Does student participate in any other activities that conflict with dance training? (I.e. swim team, cheerleading, etc.) □ Yes □ No If so, what? __________________________________________________ ___________________Please give a brief history of the student’s progress under your instruction. ____________________________________________________________________________________________________________________________What are student’s strengths? ________________________________________________________________________________________________________________________________________________________________Areas for improvement?_________________________________________________________________________Physical difficulties? ____________________________________________________________________________Any known eating disorders? (Past or present) If so, explain. ________________________________________________________________________________________________________________________________________Does student have a realistic view of his/her abilities? □ Yes □ No If not, explain. ________________________________________________________________________________________________________________________What would you like to see your student accomplish at our Intensive?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Teacher’s Signature __________________________________________ Date ____________________

Please mail directly to: Summer Intensive Workshop The Scripps Performing Arts Academy 9920 Scripps Lake Drive, Suite 105San Diego, CA 92131

Student Biographical Sketch (Due June 30)

Name:_______________________________________________________________________ | _____________ Last First Middle Prefer to be called

Do you have any medical problems that we should be aware of? If yes, please explain on separate sheet and attach.

□Yes – sheet attached □No Date of Birth:______/______/______ Age:__________ Father’s Name:_______________________________ Mother’s Name:___________________________Home Phone: (_____)_____________________ ____ Home Phone: (_____)______________________Cell Phone: (_____)___________________________ Cell Phone: (_____)_______________________Address:____________________________________ Address:________________________________City/State/Zip:________________________________ City/State/Zip:____________________________Father’s Employer:____________________________ Mother’s Employer:________________________Job Title:____________________________________ Job Title:________________________________Work Phone: (_____)__________________________ Work Phone: (_____)_______________________Parents are: □ Married □ Divorced Student lives with: □ both parents □ mother □ father Do you plan to attend college? □ Yes □ No If yes, where?_________________________________ Major:______________________ Minor:______________________ Projected Start Date:____________

• Last book(s) read:________________________________________________________________ • Favorite movie(s):________________________________________________________________ • Hobbies:_______________________________________________________________________ • What do you hope to gain from this Intensive?__________________________________________________________________________________________________________________________• How did you hear about this Intensive?________________________________________________

Student will Stay with Host Family? □Yes, please complete pages witjdrawal policy, off campus permission waiver, photo/video release, physician’s release & transportation form

□No. Please briefly explain who student will be staying with and complete, withdrawal policy, off campus permission waiver, photo/video release

RULES AGREEMENTI will work to prepare my body for the significant physical demands of this Intensive. I understand that the staff, teachers, and counselors are in a place of authority for my benefit and protection and I will honor their leadership while I am attending this Intensive. I will take all complaints or problems to a Staff Member first before calling my parents. If I have a complaint or other difficulty regarding my class level, I will talk with a Staff Member first. I realize there will be people from many different backgrounds attending this Intensive and I will show respect for all. I plan to enjoy this Intensive and to have a great time.

Signature of Applicant:_____________________________________________Date___________________ _

Dance Attire and Equipment

Necessary Supplies Check-List

Several Pairs of Pink Convertible Tights (�� will dance barefoot for Modern)

Short Black Ballet Skirt (14 inches or less) �� Intermediate Program

White Tank or Camisole Leotard �� Pre-Professional Program ONLY for demonstration performance

White Ballet Skirt (14 inches or less)�� Pre-Professional Program ONLY for demonstration performance

Pink Ballet Slippers��

Several Pairs of Pointe Shoes �� for those CURRENTLY on pointe ONLY

Several Black Leotards, Colored Leotards will be Allowed on �� TUESDAYS and THURSDAYS Only PRE-PROfEssIONaL PROgRaM ONLY

Black Character Shoes (1.5 heel recommended) �� scripps Ranch location ONLY

Black Character Skirt (below the knee to mid shin) �� scripps Ranch location ONLY Jazz Pants or Shorts �� optional

Jazz Shoes��

Large Water Bottle��

Yoga/Pilates Mat �� Intermediate sR Program does NOT need a Mat.

Foam Roller and Pinky Ball �� Recommended for Pre-Professional Program, but not required

Small Personal Towel��

Healthy Snacks��

Healthy Lunch ��

Deodorant��

Withdrawal Policy

If a student decides to withdraw from the Scripps Performing Arts Academy’s Summer Intensive 2016 program, the family must send notification IN WRITING by April 1, 2016. If notification in writing is received by April 1, 2016, the account will be refunded the tuition and housing payment (if applicable) minus a $350 non-refundable tuition deposit.

Any student withdrawing after April 1, 2016, or dismissed from the program by SPAA, will not receive a refund, credit or compensation.

If a student is injured before the Summer Intensive program begins, half of the tuition and the full housing cost will be refunded. A signed, original copy of a letter from the Physician must be sent to the School in order to refund tuition and housing. Students who must withdraw during the Summer Intensive due to injury or illness will be dealt with on a case by case basis.

I Have Read and Understand This Policy:

Parent or Guardian Signature

9920 Scripps Lake Drive, Suite 105, San Diego, CA 92131www.ScrippsPerformingArts.com * 858.586.7834

9920 Scripps Lake Drive, Suite 105 San Diego, CA 92131 858.586.7834

spaa.office@gmail.com, www.ScrippsPerformingArts.com,

2016 Permission Waiver and Off Campus Permission FormPlease Apply This Waiver to The Following Programs:

��Summer Intensive 2016 ��Nutcracker 2016

��All Classes and Rehearsals for 2016-17 School Year

Student’s Last Name: _____________________First Name:______________________ I Give Consent for Said Minor To Leave Campus Under the Following Guidelines:

Dancer is wearing � STREET CLOTHES that cover his/her dancewear fullyDancer must notify faculty or staff member of their departure and arrival �Dancer is on time for class following departure �FAILURE TO FOLLOW THESE RULES MAY RESULT IN A REVOCATION OF OFF �

CAMPUS PRIVILEGES

Check “yes” or “no”

May ride in vehicle driven by student or friend: yes _____ no ____ Specifically (optional):

Names: _______________________________________

SCRIPPS RANCH ONLY May walk to the Trader Joe’s Shopping Center in a group of 3 or more: yes _____ no ____

TORREY HILLS ONLY My 14 or older child may walk to get food in within the Torrey Hills Center: yes _____ no ____

*Students at Torrey Hills under 14 years old, must pack a lunch and will not be permitted to leave the building during program hours.

Please Sign Below to Indicate You Have Read, Understood and Accepted the Guidelines Outlined Above.

Parent(s)’/Legal Guardian’s signature:

Date:

Please complete this form and return to us at the above address. Student’s without forms on file, will NOT be allowed to leave the Academy Premises.

SCRIPPS PERFORMING ARTS ACADEMY

Photo/Videography Release (Due June 30)

Dear Student and Parent:

We often update our website and may use some pictures and video footage taken from past Intensives. Plans have been made to take updated pictures for use in future brochures and other publications representing classroom and general Intensive settings. Photos and videography would never be intentionally used in such a way to negatively reflect on their subjects. Please read and sign the release below if you consent to its conditions.

R E L E A S E

I,____________________________________ (Print student name), grant to The Scripps Performing Arts Academy, its employees, agents, and assignees, the right and permission to make, reuse, and/or publish photographic pictures or video tapings of me, which may be used in connection with my own or a fictitious name, for any purpose whatsoever including the use of any printed matter. I waive any right to inspect or approve either the finished photograph or video or the printed matter or video with which it may be used in conjunction.

Student’s Signature_______________________________ Date___________________

Print Name___________________________________

I certify that, as parent and/or guardian of the above-named student, any photographs which have been or are about to be taken by or for The Scripps Performing Arts Academy may be used for the purposes stated above.

Parent or Guardian’s Signature __________________________Date_______________

Print Name ____________________________________

Physician’s Release (Due June 30)

CONFIDENTIAL RECORD Medical Emergency Release (Due June 30) Please fill out completely. Parent is immediately called if student must be taken to doctor.Student’s Name:___________________________ Date of Birth: _________________________________ Address: _____________________________________________________________________________ Medical Insurance Carrier:_____________________ Policy # ___________________________________ Insured’s Name:______________________________ Group # __________________________________

□Photocopy of the current insurance card attached. (This saves time if student must be taken to doctor. Record is destroyed after Intensive.)

Current Physician’s Name (please print): ___________________________________________________________ Physician’s Office Phone: (_____)______________________ After-hours emergency #: (_____)_______________EMERGENCY CONTACT (This is the person we will call if we must take student to the doctor): Name:______________________________________________ Home Phone: (_____)______________ Work Phone: (_____)______________ Cell Phone: (_____)____________ Relationship: _________________________________________ CREDIT CARD INFORMATION (for cases of extreme emergency only) OPTIONAL: Card Type: □Visa □MasterCard □American Express □Discover Name on Card________________________Card #:______________-_____________-______________-_____________ Exp Date: ________/_________

• Please list any/all allergies:_______________________________________________________________• Describe any injuries in the last year:__________________________________________________________________________________________________________________________________________________________________• Any presently existing or persistent condition/infection? (i.e. asthma, bursitis, etc.)_________________________________________________________________________________• Please list any medications you are currently taking:_________________________________________________________________________________• Have you ever had an eating disorder? (If yes, please explain.)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________• Are you on a special diet of any kind? (If yes, please explain.)_________________________________________________________________________________

CONSENT FOR TREATMENTI/We hereby agree to the performance of such treatment, anesthetics, and operations on the above-named person as deemed necessary by the attending physician. ___________________________________________ ___________________________________________ Signature of Applicant Signature of Parent/Guardian (if applicant is under 18) Date:___________________________ Date: ____________________________ LIABILITY RELEASEI/We hereby release The Scripps Performing Arts Academy and their agents, employees, and volunteer assistants, from any liability whatsoever arising out of any injury, damage, or loss which may be sustained by the above-named person during the Summer Intensive. ___________________________________________ ___________________________________________ Signature of Applicant Signature of Parent/Guardian (if applicant is under 18) Date:__________________________ Date: ______________________

Physician’s Release (Due June 30)

**This form to be filled out by the Student’s physician or healthcare practitioner responsible for student’s health and well-being.**

Student’s Name: ______________________________________________________________________ The above named Student has applied for participation in The Scripps Performing Arts Academy’s 2016 Summer Dance Intensive. This program will require good health and endurance. Please fill out the form below and make any additional comments. Thank you.

1. Would he/she be able to participate in daily dance classes (4 - 6 hours)? □ yes □ no (if no, explain)_______________________________________________________________________ 2. Is he/she under a doctor’s care at this time for any reason, or is he/she taking any medications? □ yes □ no (if yes, explain) _______________________________________________________ _____________________________________________________________________________ 3. Is he/she on a special diet? □ yes □ no (if yes, explain) _______________________________ _____________________________________________________________________________ Any eating disorders? ___________________________________________________________4. Has he/she had any problems with the following?:

ALLERGIES YES NO YES NOPenicillin Back ProblemsSulfonamides FEMALES ONLYSerum Irregular PeriodsFood-Please Specify Severe CrampsOther- Please Specify Excessive Flow

5. Would you consider the applicant to be in generally good health? ______________________ ____________________________________________________________________________________ Please use the back of this form to make any additional comments regarding the applicant’s health or special limitations affecting physical, mental or emotional capabilities. Print Name: ________________________________ Physician Other: _____________________ Address: __________________________________________________Phone: (_____)_______________How long have you been the Applicant’s healthcare provider? ___________________________________ Signature: ___________________________________________ Date: ____________________________ Title: __________________________

Transportation Form (If you are traveling by plane, please get your forms in ASAP and no later than June 30)

Name: ______________________________________________________

Transportation will be provided by which of the following:

□AIRPLANE □GREYHOUND □AUTO □AMTRAK

airline: _________________________________________________

UNACCOMPANIED MINOR – This does not mean that you are a minor who is flying, but does mean that the airline you are flying with considers you an official Unaccompanied Minor and you will be released when you arrive to a designated person only and must have an adult check you in and sit with you until you board when departing. Usually there is a fee for this service. Check this block ONLY if you fall within this classification. For Unaccompanied Minors ONLY: Call the office for the name of the person who will greet you at the airport.)

□UNaCCOMPaNIED MINOR Please fill out COMPLETELY, listing all connecting flights, or send a copy of your ticket.

Trip to San Diego (Circle either AM or PM)

DepartureDate:

Departure Time:

Flight #(bus/train #):

From (city): To (city): Arrival Time:

AM/PM AM/PMAM/PM AM/PMAM/PM AM/PM

Trip Home (Circle either AM or PM)

DepartureDate:

Departure Time:

Flight #(bus/train #):

From (city): To (city): Arrival Time:

AM/PM AM/PMAM/PM AM/PMAM/PM AM/PM

AUTO, riding with: □ Parents □ Other: _________________________________________________________ Arrival in San Diego: Date:_________________ Estimated Time of Arrival:________________AM/PM Departure from San Diego: Date: ____________ Estimated Time of Departure: _____________AM/PM

○ YES, I will need transportation FROM AND TO the airport/station (PARTICIPANTS ONLY).

○ YES, I will need SPECIAL ASSISTANCE with my transportation and have written an explanation on the back.

○ NO, I will NOT need The Scripps Performing Arts Academy’s transportation assistance on arrival/departure days. □ Yes □ No If you are 18 or older, will you have your own car?