Form - Bass Coast Ballet School

Enrollment Form

How did you hear about us? *

* Indicates required field

Student's Name *

First

Last

Contact Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

School attending e.g. Cowes Primary / Newhaven College *

Where would you prefer to dance *

Cowes Wonthaggi

Class of interesst *

Does the student have any physical restrictions or behavioural issues we should know about? *

Previous dance experience *

Emergency contact name *

First

Last

Emergency contact number *

Is the student an adult - over 18 years? If not, please complete Parent's details *

Yes No

Mother's or Guardian's Name *

First

Last

Father's or Guardian's Name *

First

Last

Is there a custody arrangement we need to know about? *

Yes No

If yes, explain *

Mother's or Guardian's Mobile Number *

Father's or Guardian's Mobile Number *

Submit