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Fusion Principal: Christine ~ 0403230376
E-mail: inquiry@fusionmovementstudio.com.au
Address: 9 Normic Ave East Blaxland, NSW 2774 Links: Belly Dancing: www.lashermanas.com.au GKR Karate: www.region2gkr.com Costume Hire: www.mobilefancydress.com.au Childcare: www.littleamigoschildcare.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 * *Alternatively you can cut and paste this form and e-mail it back, or simply e-mail your choice of classes to us and fill out an enrolment pack when you arrive *
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