Course Registration Form

Student Name*

First NameLast Name

Student Name / Child 2 (if applicable)

First NameLast Name

Parent / carer contact E-mail:*

example@example.com

Photo (Optional)

Birth Date - Student 1

MonthDayYear

Birth Date - Student 2 (if applicable)

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mobile Number

Phone Number

Previous experience?:(LAMDA/RADA/ARTS AWARD)

YesNo

Select a course

If yes, please add details:

I consent to being contacted by Chalkpit Theatre Arts by phone

YesNo

I consent to being contacted by Chalkpit Theatre Arts by e-mail

YesNo

I consent to lessons being photographed / filmed for teaching / promotional materials / online safety purposes only

YesNo

I understand that 6 weeks notice must be given when ceasing tuition, or the fee paid in lieu of classes for this period

YesNo

Payment amount:

GBPPlease leave blank if you are paying by bank transfer (07-02-46 19575848) or key in the amount you would like to pay. See website for payment amounts or contact info@chalkpittheatre.com

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Additional comments / anything that would be helpful for us to know about your child?

I understand that LAMDA examination fees are in addition to classes (*please ask for details. Exams will take place 1-2 times per year depending on age, progression and experience)

YesNo

New Student Enrolment Form