2023 SCPD Registration Form

2023 SC Physie and Dance Registration Form
New member

Please check if you are a new member to SCPD and APDA for 2023
How did you hear about SCPD?
Please select from the following
Name of student*

First NameLast Name
Age of student as of 31 August 2023*
Date of birth*
Class selection - Please select all that apply.
Class Selection

Tiny tots - Monday morningTiny tots - Friday morningSCPD Petites (4-5 yrs) - Monday morningSCPD Petites (4-5 yrs) - Friday morningJuniors 5-12 yrs - Monday afternoonJuniors 5-12 yrs - Wednesday afternoon13yrs - Elite SeniorsLadiesSenior BalletNon participating club member5 - 6 years - Saturday morning (will depend on numbers)Tiny tots/ Petites - Saturday morning (will depend on numbers)
Are there any medical conditions we need to be aware of? If YES please explain*
Parent or guardian if under 18years old

First NameLast Name
Parent/ Guardian/ Member phone number*
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
I give consent for images of me/ my child to be used in publicity for the club/ APDA*

YesNo
I give consent for me/ my child's name to be used in publicity for the club/ APDA*

YesNo
I give consent for a qualified first aid officer to administer first aid to me/ my child if required*

YesNo
Emergency contact 1*

First NameLast Name
Emergency contact Phone Number 1*
Emergency contact 2*

First NameLast Name
Emergency contact Phone Number 2*
PLEASE NOTE:

This permission information MUST be completed and submitted before members can commence class. This information will also be submitted to APDA to complete your registrtaion once your APDA registration has been paid.

Additionally, registration fees MUST be paid on commencement. Due to insurance requirements, girls/ ladies will not be eligible to participate in class lessons or competitions if this fee is not paid.

Alternative arrangements for term fee payments can be made by contacting our club treasurer -

Kim Nowakowski, email: shellharbourcity.physie@gmail.com

For bank transfers -

Bank details: SC Physie and Dance Inc. BSB: 062-835 ACCOUNT: 1008 1237
Agreement for Participation

I release and hold harmless Shellharbour City Physie and Dance and APDA, it's teachers and helpers from any and all liability sustained by the participant while in and upon the premises, at competitions or any other related events. I have read the pricing policies and agree to abide by all terms. I have also read the SCPD and APDA Social media policies, SCPD and APDA Members Code of Conduct and the SCPD Member Protection policy (available to read on the 'Contact' page of the SCPD website) and agree to abide by all terms, I understand that photographs and video footage of myself/ my child may be used in Shellharbour City Physie and Dance and APDA promotional materials, social media including the website, unless you selected ''NO'' in the above consents.
Please tick*

I agree to the terms of participation as descibed above
Should be Empty:

2023 SC Physie and Dance Registration Form