ONLINE ENROLMENT Please fill in the form below to enrol for our classes! Sign Up Date: Child's Full Name* First Last Child’s Date of Birth:*Parent's Full Name:* First Last Home Phone Number:Mobile Number:Email:* Address: Street Address Address Line 2 City State Post Code Emergency Contact Name:* First Last Emergency Phone Number:*How did you hear about the school? If you were referred, name referral:MEDICAL INFORMATIONPlease tick if your child suffers form the following: Heart Condition Blackouts Asthma Migraines Other If Other, please specifyIs your child presently taking medication?NoYesIf yes, please tell us more: eg. state the name of the medication, side effects. Includes asthma puffers, nebulisers etcPlease tick if your child is allergic to any of the following: Penicillin Other Drugs Any Food Other If Other, please specifyDoes your child suffer from any anxieties or learning disabilities?NoYesIf yes, please specify:Please indicate anything else we may need to know about: Eg: Disability, wearing glasses, recent injuries/sicknesses, custody arrangements etcFEE INFORMATIONName of Person responsible for paying fees: First Last Phone Number*If different from contact number provided aboveEmail *If different from email provided aboveI have read the Fee Information and undertake to pay my fees in accordance with the information provided therein* Yes FACEBOOK INFORMATIONWe have two facebook pages – an open page entitled ‘Helen Clark School of Dancing’ and a closed page entitled ‘Helen Clark School of Dancing Team’. We use the open facebook page for publicity and promotional purposes. The closed page is only accessible by staff, teachers and members of the dancing school. We use the closed facebook page to convey information and reminders about upcoming events (all important information is also emailed), report on students’ progress and display fun class photos and hilarious moments. If you are on facebook, it is strongly recommended that you join both facebook pages. So that we can monitor and maintain our high level of privacy on the closed facebook page please provide the name/s of the parents or guardians that will be joining the closed facebook page: Parent / Guardian 1: First Last Parent / Guardian 2: First Last CONCERT RELEASEEach year we hold an end of year concert. Photographs of all students are displayed in the concert program and associated materials. The concert is also filmed by a professional filming company. If you want your child to be involved in the end of year concert you must indicate your permission below. I give permission for my child/ren to be photographed and filmed by Helen Clark School of Dancing (or its appointed agent) as part of the end of year Concert and for such photographs to be displayed in all associated material such as the program, DVD cover and promotional material. *NOTE: Concert Photos (including videos) may be used for future promotional materialINDEMNITYI have indicated in this form any health problems or conditions of which the studio should be aware (such as heart, back, medical, allergy, muscular, pregnancy, diabetes, epilepsy, chemical or neurological condition, special medication, knee/kidney/shoulder problems, etc.). I understand that risk of injury is inherent in any physical activity and I, on behalf of myself and my child, knowingly and voluntarily accept that risk. I hereby waive and release Sarah Zeidler individually and Helen Clark School of Dancing and its staff from any and all claims or damages of any kind arising out of my child’s participation in the classes of Helen Clark School of Dancing. I further certify that the aforementioned student is in proper physical condition to participate in the exercise/dance program. I authorise Sarah Zeidler or her designated agents (being teachers or administrators of Helen Clark School of Dancing) to obtain medical treatment for my said child in emergency situations where I cannot be reached in time to authorise the treating physician to provide such emergency medical services. I understand that I am responsible for any medical expenses and that the absence of health insurance does not make Helen Clark School of Dancing responsible for payment of medical expenses. This authority includes the power to authorise any and all treatment deemed necessary under the circumstances by a licensed physician. This power is in essence a power of attorney and shall remain in effect for one year from the date signed below.* Yes PRIVACY STATEMENTThe personal information we collect from you will be used to perform all administrative functions associated with your child being involved in dancing classes, activities and events conducted by Helen Clark School of Dancing. It will also be used to ensure that your child has a safe and enjoyable time. Failure to supply the information will limit our ability to provide a safe and enjoyable environment. Health information will be used solely to ensure your child receives optimum health care. If we want to use this information for any other purpose, we will ask for you consent.