Please enter Account Reference (shown as AC Ref at top right of recent invoice):

Account Reference *

Surname or family name

Surname

Submitted by

Email

Student Details

Student Surname / Family name (if different from above):

Student Surname

Student Address (if different from Account Address above):

Student Address

Student 1 Name

ISTD PIN (if known):

ISTD PIN

Please enter Date of Birth or Adult below:

Date of Birth

Adult? Select one No Yes

Orientation Select one Male Female Other

Please state the ULN (Unique Learner Number) for the student if known:

ULN

Subject 1 Select one Ballet Modern Theatre Tap Commercial Jazz Musical Theatre Contemporary Dance

Class Code of preferred class(es):

Class Codes

Subject 2 Select one Ballet Modern Theatre Tap Commercial Jazz Musical Theatre Contemporary Dance

Class Codes

Subject 3 Select one Ballet Modern Theatre Tap Commercial Jazz Musical Theatre Contemporary Dance

Class Codes

Student 2 Name

ISTD PIN (if known):

ISTD PIN

Please enter Date of Birth or Adult below:

Date of Birth

Adult? Select one No Yes

Orientation Select one Male Female Other

Please state the ULN (Unique Learner Number) for the student if known:

ULN

Subject 1 Select one Ballet Modern Theatre Tap Commercial Jazz Musical Theatre Contemporary Dance

Class Code of preferred class(es):

Class Codes

Subject 2 Select one Ballet Modern Theatre Tap Commercial Jazz Musical Theatre Contemporary Dance

Class Codes

Subject 3 Select one Ballet Modern Theatre Tap Commercial Jazz Musical Theatre Contemporary Dance

Class Codes

MEDICAL DECLARATION AND EMERGENCY ACTION

Please give details below of any medical condition (e.g. asthma) which may affect the participating in a physical activity of ny of those students listed above, together with details of any medication required, and whether he/she is able to administer this his/herself:

Student 1

Student 2

Ambulance in emergency if Parent / Guardian cannot be reached

In the event of an emergency, should a teacher or other representative of the School consider it necessary, I agree to an ambulance being called for any of the students listed above (the School's policy is ALWAYS to contact a parent via the provided numbers in the first instance where time allows)

Ambulance * Select one Accept Decline

Signed *

Relationship * Select one Parent Guardian Self