ZCLUB KIDZ - DANCE FITNESS
CHILD REGISTRATION FORM FOR ZCLUB ZUMBA KIDS® PROGRAM
Email address *
Your Shining STARZ Name *
Your answer
Your Shining STARZ LAST Name *
Your answer
Gender *
Your Shining STARZ Date of Birth *
MM
/
DD
/
YYYY
Your Shining STARZ Age *
Your answer
Your 2nd Shining STARZ Name
Please leave blank if you are registering only one child
Your answer
Your 2nd Shining STARZ Gender
Please leave blank if you are registering only one child
Your 2nd Shining STARZ Date of Birth
Please leave blank if you are registering only one child
MM
/
DD
/
YYYY
Your 2nd Shining STARZ Age
Please leave blank if you are registering only one child
Your answer
Super Mum/Dad/Guardian Name *
Your answer
Super Mum/Dad/Guardian DOB
Day & Month Only
Your answer
Relationship to Child *
Parent/Guardian/Aunt/Uncle etc
Your answer
Email *
Your answer
Home Address *
Your answer
Line 2
Your answer
Suburb *
Your answer
Postcode *
Your answer
Phone number *
Your answer
Where can you be reached while you child is in the program?
Your answer
NOW FOR THE SERIOUS STUFF - EMERGENCY CONTACT NAME *
Parents cannot be listed as emergency contacts. List the name of one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you and at least one person listed must be close to facility where the class is being held and able to take responsibility for the child in case you cannot be contacted.
Your answer
Emergency Contact Phone number *
Your answer
Emergency Contact Relationship to Child *
Your answer
Authorisation of other individuals to pick up child
Please state name, phone & relationship to child
Your answer
Health Conditions
Please list any health issues that would be important should any medical attention be required
Your answer
NOW LETS ROCK THIS!
Please list any interests, concerns or what you would like to your child to gain from the program
Your answer
PART A – INJURY: (Mandatory) I realise that participation in this activity involves risk of injury. I hereby assume all delineated risk which could occur by reason of participation and also waive, release and forever discharge employees, representatives and all others from any and all responsibility and liability for injury or damage resulting in participation of this activity. *
PART B – USE OF MEDIA: I, herby grant permission to use my child’s photograph and/or video recording in its promotional materials and publicity efforts. I understand that the photographs or videos may be used in a publication, print ad, direct-mail piece, electronic media (e.g. video, CD-ROM, Internet/WWW, facebook), or other form of promotion. I release and forever discharge employees, representatives and all others from liability for any violation of any personal or proprietary right I may have in connection with such use, and waive the right of any compensation, royalties arising or related to the use of my image or recording. *
PART C – USE OF CONTACT DETAILS: I authorise my email & phone to be used for notification purposes of events & classes associated with ZCLUB KIDZ. I understand that I may request at any time for my details to be removed from the database and no further contact will occur. *
SIGNATURE *
Typing your name, provides an electronic signature of the agreed terms and conditions.
Your answer
SUPER EXCITED!! WE ARE!!!! LETS HAVE A ROCKING GOOD TIME! THANK YOU KINDLY FOR REGISTERING YOUR SHINING STAR WITH ZCLUB KIDZ!
From a scale of 1 - 5 .....how excited is your child?!! We aim for excellence, fun, excitement, adventure & learning life skills! If you are not 100% satisfied with the program, please let us know as we are committed to providing the ULTIMATE PARTY experience!
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