Serenity Pride Enrolment Form

Serenity Pride Enrolment Form
PARTICIPANT INFORMATION:
Participant Name*

First NameLast Name
Birth Date*

DayMonthYear
We will be paying:*
NDIS Number (if applicable)
Plan Manager Name (if applicable)
Plan Manager Email (if applicable)
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
ENROLMENT AND PAYMENT AGREEMENT
I,   First Name*   Last Name*, am enrolling my child/teen,   Participant's name*, into Serenity Pride's LGTBQIA+ Social Group.
I,   First Name*   Last Name*, understand and agree that I will be invoiced $35 for Wednesday 1st of March and that this amount is due before the commencement of group. I understand and agree that refunds will not be issued.
Signature*
First Name*   Last Name*
Date*
FOOD AND PHOTO/VIDEO CONSENT
I,   First Name*   Last Name*, consent to my child/teen,   Participant's name* receiving food and taking part in making food. I have disclosed any food preferences, intolerances, and/or allergies below.

YES   NO*

I,   First Name*   Last Name*, consent to my child/teen,   Participant's name*, being photographed/filmed during the Serenity Pride group session, and for any resulting images or video to be used in marketing materials (online and hard copy) by Serenity Social & Support Services.
YES   NO*
Any food preferences, intolerances, allergies.
Other comments
Should be Empty:

ENROLMENT AND PAYMENT AGREEMENT