Class……………………………………… Day 1/Time…………………

Class……………………………………… Day 2/Time……………………

Child Name……………………………................................................

Child Name……………………………................................................

Parent Name…………………................................................ (if under 18)

Age………….. School Attended ..............................................(if under 18)

Address………………………………………………………………………

…………………………………………………………….Postcode………

Tel: Home…………………Mobile……………………Work………….......

Email………………………………………………………………………….

Emergency Contact

Name…………………………….................................

Emergency

Tel……………….........................................................................

Asthma/Allergies to Nuts Dogs or Other: (circle)

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Epi Pen required yes / no

Disabilities

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How did you hear about us?

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I wish to pay by: Cash Credit Card Visa MasterCard

Amount: $..................... Paid in Full by Cash Direct Deposit Credit Card Gift Voucher

Card Number .... …. …. …./…. …. …. …./…. …. …. …./…. …. …. ….

Expiry Date …. …./…. …. Cardholders Name………………………….

Cardholders Signature………………………...................Date………….

Office Use Only:

Receipt Number…………………………….

Date…………………………….