CICB Competition 2024 Video Audition Registration and Payment Form

Student Information
Student Name:*
First Last
Student Date of Birth:*
MM slash DD slash YYYY
Most Recent CCA Exam Passed:*
Sponsoring Coach Information
Sponsoring Coach:*
First Last
Sponsoring Coach Phone:*
Sponsoring Coach Email*
Name of Classical Variation*
Name of Contemporary Solo*
Choreographer of Contemporary Solo*
Video Audition Registration Fee Quantity*
Price: $125.00
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Credit Card Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
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Student Information