Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Background (select all that apply):

Dancer

Choreographer

Actor

Director

Movement enthusiast

Payment Options *

If paying ONLINE: Please select your option from the dropdown menu below this form and click the 'Pay Now' button. You will be taken to the Paypal site to complete your payment (fees apply). If paying by MAIL: Please make checks payable to Dance Entropy Inc. Include 'VG/DE Summer Dance Intensive' on the memo line. Send to: Valerie Green/Dance Entropy Inc. 37-24 24th St. Suite 211 Long Island City, NY 11101

• Mail-in Early Bird: $450 until June 30th (postmarked)

• Mail-in Full Cost: $500 July 1st or after (postmarked)

• Mail-in Scholarship: $250

○ Online Early Bird: $465 until June 30th (includes PayPal service fee)

○ Online Full Cost: $518 July 1st or after (includes PayPal service fee)

○ Online Scholarship: $260

Payment Confirmation *

I confirm that I am paying ONLINE

I confirm that I am paying WITH CHECK