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Campbell Primary Student Registration Form
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1
Parent/Guardian Full Name
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First Name
Last Name
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2
Child Full Name
*
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First Name
Last Name
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3
Child Date of Birth
*
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4
Phone Number
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Area Code
Phone Number
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5
E-mail
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example@example.com
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6
Does your child have any medical conditions we need to be aware of? e.g. allergies, asthma
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7
Is there anything else we need to know about your child to help them have a positive experience in class?
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8
Do you have any other questions?
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9
I understand that after submitting this form my child will be booked into class from 3-4pm beginning in week 1 of Term 4 (October 17)
Yes
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10
Payment
9 week dance term $15 per lesson
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Great Product Name
$20
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Great Product Name
$20
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ORDER SUMMARY
Total cost
AUD
Campbell Primary School Term 4 Classes
9 week dance term $15 per lesson
$
135.00
AUD
+
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First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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