REIGISTRATION FORM

To ensure a place in 2011 classes, please complete and send to:

Debra Whitten School of Dance
C/- 14 Farr- Jones Court,
Daisy Hill QLD 4127
Phone: (07) 38087823
0419 679 063

New Students: Yearly Enrolment Fee: $20.00

(Please enclose, or will be added onto Account)

Student’s Name:

Date of Birth: Age:

Address:

Suburb: Post Code:

Telephone: (H) Mobile:

Telephone: (W)

Email:

Parent(s) Name:

Class Title Grade Tick Number per week

Tinies
Classical Ballet
Pointe
Contemporary
Jazz
Tap
CSTD Jazz (Grade 3-8)

Indemnity

I hereby give permission for my child or myself (if 18 years or over) to participate in dance classes. I
fully understand this is at my child’s/own risk, and that all care will be taken with students, but no
responsibility will be accepted by the school or those involved with the school.

Some physical contact may be necessary by the teacher to demonstrate exercises or techniques, or if a
member of the staff needs to administer first aid. In the event of a medical emergency and where a
parent cannot be contacted, I authorise the dance school to seek medical advice/attention for my
child at a hospital or medical centre.

Name of Parent:

Signature: Date

Are there any medical conditions we should know about?