Clone of Course Registration Form

Consultation / Trial lesson
Student Name*

First NameLast Name
Contact E-mail:*
example@example.com
Birth Date

MonthDayYear
Gender
Mobile Number

Phone Number
Appointment
Select a course
Previous experience?:(LAMDA/RADA/ARTS AWARD)

YesNo
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
Additional comments / anything that would be helpful for us to know?

Payment amount:

GBPPlease adjust payment amount accordingly: £10 for a one off trial / consultation / group class. £18 for a solo lesson. Alternatively, please enter the full term’s fee or monthly payment amount agreed by Chalkpit Theatre Arts.

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

Should be Empty:

Consultation / Trial lesson