...........................................................................................................................................................................................................................
SUMMER 2017 - ONLINE REGISTRATION 
If registering for the Center Stage Program only, you may submit your registration form but acceptance into the Center Stage Program is by audition only.

Student Name
Birth Date
Age as 
of 6/25
Grade in 
Sept 2015
Student's Home Address
Street
City
State
Zip
Student's Email
Student's Cell Phone
Parent/Guardian Name(s)
Mother's Cell:
Father's Cell:
Parent/Guardian Email
Home Phone:
/Address (if not Guardian above):
Emergency Contact Name/Relation to Student
Emergency Phone
List any information Conservatory Staff should know about your child (All known allergies (i.e. food, medicine), health/medical issues (i.e. asthma, diabetes, chronic health issues), learning issues):
How did you hear about Pineda Summer Conservatory?
Grades 2-5 | Monday - Friday | 9a-2:50p


Grades 6-9 | Monday - Friday | 9a-2:50p


Grades 9-12 | Monday - Friday | 9a-3p
By audition appointment only. 
Incoming 9th graders and graduating HS Seniors welcome!
I.  Student Information
II.  Payment Information
$795 Tuition 
(includes $100 NON-REFUNDABLE fee)

$830 Tuition 
(includes $100 NON-REFUNDABLE fee)

$830 Tuition 
(includes $100 NON-REFUNDABLE fee)
PAYMENTS POLICIES 
(please read and complete certification statement)

• Check and credit/debit cards accepted. 

• Payments can be made in full or in two (2) equal installments, the first due with the submission of your application and the second due on or before May 1st.

• All card payments are subject to a $25 processing fee.  If paying by installment, you will only be charged one processing fee due upon first payment.

• Checks should be made out to "Pineda Conservatory" and mailed to:



• YOUR CHILD IS NOT REGISTERED UNTIL WE RECEIVE A TUITION PAYMENT.
Please verify you have read and understand the Pineda Summer Conservatory payment & refund policies by entering your initials below.
I will be making my tuition payment
Pineda Conservatory 
1171 Terrill Road
Scotch Plains, NJ 07076
REFUND POLICIES 
(please read and complete certification statement)

• Full refund (less a $25 administrative fee) will be made if requested by May 1st. 

• NO REFUNDS WILL BE GRANTED AFTER MAY 1st.  
Enter initials here:
Check program:
PLEASE PRINT A COPY OF THIS PAGE FOR YOUR RECORDS BEFORE YOU SUBMIT.  
Once you submit, you will be automatically directed to our payment page where you may pay using debit/credit card.
(once you submit registration, you will automatically be taken to our payment page)
Pineda Conservatory of the Performing Arts a 501(c)(3) non-profit arts organization
PCPA @ FUMC, 1171 Terrill Road, Scotch Plains NJ   •   (908) 731-1377   •   thepinedaconservatory@gmail.com
MaleFemale
Father orMother's Name
I hereby certify that all the information provided on this form is true and complete to the best of my knowledge.
STARLIGHT THEATRE
SPOTLIGHT THEATRE
CENTER STAGE
In fullIn two (2) installments