Newcastle PCYC, Cnr Young & Curley Rds, Broadmeadow 2292 AVALON CIRCUS ACADEMY Yearly Enrollment Form STUDENT DETAILS Surname: _______________________________ DOB: ____/____/_____ Given Name: _____________________________ Age in 2015: ___ yrs. Gender: Male / Female Address: _____________________________________________________________________________ Suburb: ____________________ State: ____________________ Postcode: __________ Contact Number: (H) ____________________ (M) ____________________ (W) ____________________ Email Address: ____________________________________________ Do you use Facebook: Yes / No MEDICAL HISTORY / ALLERGIES Does this student have medical history or allergies Avalon Circus Academy & Circus Avalon should know about? Asthma Food Allergy Seizures Bee/ Wasp Allergy Heart Condition Skin Allergy Diabetes Muscular injury Details/Other: ________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Ph: 0409 495 747 www.circusavalon.com.au [email protected] Newcastle PCYC, Cnr Young & Curley Rds, Broadmeadow 2292 EMERGENCY CONTACTS (1) Name: __________________________________ Phone: ____________________ Relation: ________________________________ Mobile: ___________________ Email: ___________________________________ Facebook: Yes / No (2) Name: __________________________________ Phone: ____________________ Relation: ________________________________ Mobile: ___________________ Email: ___________________________________ Facebook: Yes / No Ph: 0409 495 747 www.circusavalon.com.au [email protected] Newcastle PCYC, Cnr Young & Curley Rds, Broadmeadow 2292 CLASS AGE STRUCTURE 7 -12 10 - 14 8-18 18+ (Not for beginners) 18 + (Beginners) Intense aerials (Beginners welcome) SESSION TIME (Please Circle) Tuesday Wednesday Thursday Friday Saturday 3:45– 5:00pm 6:00 – 7:00pm 3:45 – 5:00pm 3:45 – 4:45pm 9:00 – 10 am 5:00 – 6:15pm 7:00 – 8:00pm 5:00 – 6:15pm 5:00 – 6:30pm 10:00am- 2:00pm 6:30 – 8:30pm 6:30 – 8:30pm FEE STRUCTURE (please circle) 1 Session or child 2 Sessions or Children 3 Session or Children 4 Sessions or Children Intense Aerials Class = $140 = $265 = $380 = $470 = $30 5% Discount 10% Discount 15% discount Per Class PLEASE CIRCLE THE TERMS YOU WISH TO ENROLL IN: Term 1: 03/02 – 02/04 Term 2: 21/04 – 26/06 Term 3: 14/07 – 18/09 Term 4: 06/10 – 15/12 PAYMENT Enrolled: __/__/____ Payment made: __/__/____ PAYMENT METHOD Cash Ph: 0409 495 747 Check www.circusavalon.com.au Online [email protected] Newcastle PCYC, Cnr Young & Curley Rds, Broadmeadow 2292 DISCLAMAIMER Avalon Circus Academy trainers will carefully guide your child through circus activities, but cannot guarantee total safety. AGREEMENT & CONSENT (PLEASE TICK) I, _________________________________ hereby affirm I am aware that:          Circus activities involve some personal risk that may result in injury. I accept personal responsibility for any injury which may occur. I give permission for an ambulance to be called if considered necessary. I understand and agree that my instructor(s), volunteers, riggers or contractors may not be held liable for injury. I agree that if my child does not follow reasonable instructions from trainers, they may be excluded from the session and possibly removed without refund. I understand that to teach circus skills may require physical help which may require physical contact. I understand that term fees must be fully paid by week two of enrolled term. (Unless specified) My email addresses and related may be used to send emails about Avalon Circus Academy I have completed this form fully and correctly. Signature: ________________________ Date: __/__/____ MEDIA RELEASE CHOICES (please circle)   I give / do not give permission to use photos or video of the participant for Avalon Circus Academy or Circus Avalon promotional material. I give / do not give permission to use student name in photo or video promotional material Signature: ________________________ Date: __/__/____ OFFICE USE     All details completed in full. Agreement and consent release signed. Media release signed. Entered into student database. Ph: 0409 495 747 www.circusavalon.com.au [email protected]