Student Name: _______________________________________________________________________ Student Address:______________________________________________________________________ Post Code: __________ Student Home Phone: _______________ Student Mobile: __________________ Email Address:________________________________________________________________________ (CPD Information only) Birthdate: ____________________________ Age as 01/01/15: ________________________________ Year / Date commenced at CPD: ___________ Other Siblings dancing at CPD ____________________ Parent / Guardians:_______________________ Parent / Guardian Contact No: ___________________ Emergency Contact Name & No: _________________________________________________________ (Must be different from above) Relevant Medical Conditions/Injury: ___________________________________________________________________________________ ____________________________________________________________________________PTO___ Please list the classes you wish to participate in: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ____________________________________________________Total hours per week:_____________ PLEASE READ BELOW & SIGN ALL RELEVANT CLAUSES: Photography & Videoing may be used during class, at competitions and events throughout the year. I am aware that my son/daughter may be featured and this may be used for promotional advertising and/or maybe displayed in the studio or at the concert. SIGN _________________________________________ DATE: ___________________________ In the event of an emergency an ambulance shall be called & any costs incurred are not covered by Casey Priddle Dancers. SIGN _________________________________________ DATE: ___________________________ Troupe class students will be required to participate in competitions some weekends and during the school holidays. SIGN _________________________________________ DATE: ___________________________ I have filled in all details above correctly and have read and understand all information in the CPD Information Booklet 2015. SIGN _________________________________________ DATE: ___________________________