Fusion Principal: Christine ~ 0403230376                                     

          E-mail: inquiry(at)fusionmovementstudio.com.au   

 Nb. Please replace the (at) with the symbol; we do this to prevent spam on our website, thanks.

          Address: 9 Normic Ave East Blaxland, NSW 2774

           Links: Belly Dancing: www.lashermanas.com.au

                      GKR Karate: www.region2gkr.com 

                      Costume Hire: www.costumeone.com.au

Enrolment Form:

► STUDENT DETAILS:

► Name: ___________________________________________________________

► Address: _________________________________________________________

► Phone: ______________________ Mobile: ______________________________

► E-Mail ___________________________________________________________

► Date of birth: _____________________________________________________

► Medical information: ________________________________________________

► School: ____________________________________ Grade: ________________

► How did you hear about us? ___________________________________________

► PARENT/GUARDIAN DETAILS:

► Name: ____________________________________________________________

► Relationship to student: _______________________________________________

► Phone: _______________________ Mobile: ______________________________

► CLASS CHOICES:

 ► DISCLAIMER:

I, the undersigned parent/guardian/student (if over the age of 18) agree that any activities in which he/she/I shall partake in, is entirely at his/her/my own risk. In the event of an accident/illness/injury, I authorise for the teacher/instructor to administer any medical assistance that my child/myself may require.

I am aware that all fees are required at the beginning of the term and if my child/myself cannot attend a class, full fees must still be paid, however a make-up class may be taken depending on availability. I agree to contact the studio principal as soon as possible if I cannot pay my fees on time.

Signed: ________________________________ Date: ___________________________

 ► CONSENT TO RELEASE:

 I/we hereby give permission for Fusion Movement Studio to print, copy, display, and publish any photos or video footage of my child/myself that may be reproduced in Fusion Movement Studio's foyer, studio, flyers, newsletters, website, video or any other promotional material taken during classes and performances.

Signed: _________________________________ Date: _________________________

* Please print and return to Fusion Movement Studio or you can cut and paste this form and e-mail it back to us *