CIRCABILITY CLASS REGISTRATION FORM
Please fill out one form for each participant.
PARTICIPANT INFORMATION
Participant Name: *
Your answer
Age: *
Your answer
Gender (please tick)
Goal of attending class:
Your answer
Any Special Needs/Medical conditions:
Your answer
Ethnicity:
Your answer
Parent/Caregiver Name: *
Your answer
Mobile: *
Your answer
Email: *
Your answer
CLASS PAYMENT INFORMATION
Please make note of any new dates/times/payment applicable to your chosen class
Please select which class you would like to register for *
Payment Regularity (please tick) *
Required
Payment Method (please tick) *
Required
*Organisation that pays my class fee (if applicable)
Your answer
PARTICIPANT CONTRACT.
Circability take all due care that our classes are a safe and fun experience but learning circus skills involves risk. We all have a shared responsibility to keep ourselves and everyone else safe. By ticking the box below you agree to these conditions. *
Required
RELEASE FORM FOR USE OF PHOTOS/VIDEOS ON WEB PAGE, SOCIAL MEDIA, etc.
(We often take pictures in class)
I, being either the person pictured or legal guardian or attorney of the person/s pictured grant permission to use material captured during the course of my involvement with Circability without reservation.Please tick which applies *
Required
Date *
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/
DD
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Circability Trust, PO Box 78414, Grey Lynn, Auckland 1245 Ph 09 3613801 info@communitycircus.co.nz
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