Application for Participation
CircusWA initiative with the support of DADAA

$50 per term

Empowering children and teenagers to imagine more and dream beyond their body's abilities through a special circus program filled with tricks and wonder.

This program is designed for children and teenagers living with disability. Programs will begin in July 2021 and run as Holiday Programs and in term classes.

Once you have filled out this form, someone from the CircusWA office will call you to discuss.
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How did you hear about this program?
Which programs are you interested in attending
First name and surname of young person being enrolled
Address (if this is confidential please just include the location area)
Date of Birth
Mobile number - of primary carer.
Secondary mobile number - include name and if relevant, the organisations name and office number.
Email address.
Describe any of your child's past experience in the arts.
Is your child of Aboriginal or Torres Strait Islander descent?
Clear selection
What language do you use at home?
Does the young person enrolling require a support worker when attending activities? NB: Participants who require support should attend with their own support carer/parent - this fee is not covered by the program.
Clear selection
Gender Identification
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Are you filling out this form for:
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If for someone else's child, what is your relationship to the child?
Does your child have a physical therapist who would benefit in attending some or all of this program? If yes: List their name, contact details and Organisation (if available)  
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