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The Lucy Gunter Dance and Theatre Arts Centre Ltd
REGISTRATION / ENROLMENT FORM
*Registration Fee Please send a cheque for the sum of £11.75 made payable to
“The Lucy Gunter … Ltd” with this form to The Lucy Gunter Dance and Theatre Arts Centre, Unit 9 Morland Industrial Park, Morland Road, Highbridge, Somerset, TA9 3ET
FULL NAME OF PUPIL………………………………………………………………………………………
DATE OF BIRTH………………………………………AGE………………………………………………
ADDRESS………………………………………………………………………….................POSTCODE ………………………………………
Tel. No’s Home……………………………………...Mobile…………………………………………Work……………………………………
Names of Parents / Guardians Mother: Mrs, Miss, Ms…………………………………………
Father: Mr……….. …………………………………………………………
NAME & ADDRESS (IF DIFFERENT FROM ABOVE) OF PERSON TO WHOM INVOICES SHOULD BE ADDRESSED.
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Contact No. ……………………………………………………
Dr……………………………………… Surgery & Tel. No ……………………………………………
ALTERNATIVE PERSON TO CONTACT IN THE EVENT OF EMERGENCYS (N.B A LOCAL PERSON PLEASE)
NAME……………………………………… Tel. No. …………………………………………………..
Relationship to student (Grandparent / Aunt / Family Member or Friend)
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In the event of my child requiring emergency treatment and the principal being unable to contact me, I give consent for the members of staff accompanying my child to approve the application of any emergency treatment including anaesthetic advised by the medical authorities for the well being of my child.
PLEASE STATE ANY MEDICAL DETAILS (INCLUDING SYMPTONS / ATTACKS / MEDICATION ETC) AND / OR ANY DISABILITY OR FAMILY SITUATION THAT MAY AFFECT LEARNING.
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WHERE DID YOU HEAR ABOUT US? |
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Yellow Pages
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Phone Book
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Newspaper
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Poster/leaflet
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Word of mouth
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Other please state
Please tick the ethnic group below of which the person named on this form belongs to:
ETHNIC CLASSIFICATION |
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WHITE BRITISH
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IRISH
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ANY OTHER WHITE BACKGROUND
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MIXED WHITE & BLACK CARIBBEAN
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WHITE & BLACK AFRICAN
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WHITE & ASIAN
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AMY OTHER MIXED BACKGROUND
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ASIAN OR ASIAN BRITISH INDIAN
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PAKISTANI
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BANGLADESHI
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BLACK OR BRITISH CARIBBEAN
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AFRICAN
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ANY OTHER BACKGROUND
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CHINESE
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OTHER ETHINIC GROUP
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Please state classes to be attended: Days & times
DECLARATION: I HAVE READ, AGREE WITH & UNDERSTAND THE CENTRES POLICY (TERMS & CONDITIONS). I AGREE TO PAY THE DUE BALANCE ON OR BEFORE THE FIRST LESSON OF EACH TERM. I WILL GIVE A TERMS NOTICE IN WRITING TO THE PRINCIPAL IF MY CHILD WITHDRAWS FROM CLASS OR PAY A FULL TERMS FEES IN LIEU OF THAT NOTICE. I ALSO AGREE THAT PHOTOGRAPHS AND/OR VIDEO MAY BE TAKEN OF THE PERSON NAMED ON THIS FORM DURING ANY CENTRE PRODUCTION AND UNDERSTAND THAT IF I DO NOT AGGREE, THAT PERSON WILL NOT BE ABLE TO TAKE PART IN ANY PRODUCTION.
PLEASE ENCLOSE THE REGISTRATION FEE OF £11.75 (Not applicable for adult classes or under 3 yrs)
SIGNED……………………………………………………………DATED………………………………………………………………………..
(Parent, Guardian, pupil over 18)
PRINT…………………………………………………………………..
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