Language and Culture Club

Culture Club Registration Form

Learn language and Culture for ages 5 and above
CHILD INFORMATION:
Child Name*

First NameLast Name
Birth Date*

DayMonthYear
Age*
YesNo
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityRegion

Post CodeCountry
E-mail*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact (if different from above)
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child:
MEDICAL INFORMATION
GP Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
Health and Special Needs: Please state details of any known medical conditions, allergies or special needs we should know about.
PARENTAL CONSENT
- I hereby grant permission for my child to participate in the club's activities.
- I agree to the terms and conditions outlined by the Club, including policies on behaviour, safety and privacy.
- I consent to photographs and videos of my child being taken and I understand this may used for promotional purposes by the Club.
YesNo
By clicking submit you agree that all information provided are correct and you agree to the club storing your child's information in accordance to GDPR. You also accept responsibility for informing the Club of any changes to the details above.
Should be Empty:

Culture Club Registration Form