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Email: T. 02 4947 4080 M. 0432 040 092

ENROLMENT FORM 2011 New Student Returning Student Class: Baby Ballet (3/4 years) – Kanwal (Wednesday) Class 1 – 9.45am to 10.30 Berkeley Vale (Thursday) Class 1 – 9.45am to 10.30 Toukley (Saturday) Class 1 – 9.45am to 10.30 Class: Kinder Ballet (5/6 years) - Toukley (Saturday) Class 1 – 10.45am to 11.30 DETAILS OF DANCE STUDENT: Surname:____________________________First Name: ____________________________ Preferred name (nickname)_________________________ Male Female Date of Birth_____/____/_____ Age as of January 2011_______________ Does your child attend Preschool School Day Care Other PARENT/CARER: Family or Surname______________________________________ Given Name_______________________________________ Relationship to student_______________________________________________ Address: _________________________________________________________________________________ Post Code__________ Telephone: ( )____________________ Email: ___________________________________@_________________________________________________ (Please note we send most correspondences via email. If you change your email please notify us immediately.) Mobile (Mother) ________________________(Father)________________________ EMERGENCY CONTACT DETAILS 1. Contact Name:__________________________________________ Telephone:_____________________ Mobile:____________________ Relationship to student___________________________________________________ DOCTOR CONTACT DETAILS: Name:____________________________________________________ Address: ______________________________________________________________________________ Doctor’s telephone:______________________________________ MEDICAL CONDITIONS/DISABILITIES/SPECIAL NEEDS: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Please list ALL Adults who can collect your child after class: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ How did you find out about Central Coast Baby Ballet? ______________________________________________________________________________________________________ PHOTOGRAPHS AND VIDEOS Occasionally photographs and videos may be taken of individual students and classes of students for promotional and/or media releases. If you do not wish your child to be photographed or videoed under any circumstances, please sign the statement below. I do not wish my child to be photographed or videoed under any circumstances. Signature__________________________________________________ Date_______________________ FIRST AID / MEDICAL CONSENT I consent for staff to administer basic First Aid, which will include band-aids, bandages, soothing creams and antiseptic. In the case of emergency and a parent or guardian are not present, staff will call an ambulance and contact the phone numbers as indicated. Signature__________________________________________________ Date_______________________ Applicant’s declaration I declare that the information provided in this Enrolment Form is, to the best of my knowledge and belief, accurate and complete. I recognise that, should statements in this application later prove to be false or misleading, any decision made as a result of this application may be reversed. I have read and agree to abide by the Terms, Regulations and Policies stated by Central Coast Baby Ballet. Signature__________________________________________________ Date_______________________ Complete and return this form to: Postal: 154 Pacific Highway, Jewells 2280 OR Email: _______________________________________________________________________________________________________________________ OFFICE USE ONLY -----------------------------------------------------------------------------------------------------------------------------------------------------DATE ENROLLED: CLASS ENROLLED: Time: Location: FEES: Term 1 Term 2 Term 3 Term 4 Staff Initials


Enrolment Form 2011