Youth Circus Enrollment and Direct Debit Form 2024

Youth Circus Regular Class Enrolment Form 2025 - 2026
We require the information on this form for all Youth Circus students, including those that are returning to us. Thank you for your co-operation.
Your Details
Parent/Carer Name*

First NameLast Name
Email*
Youth Circus communication is primarily via email and we avoid paper letters where possible to reduce our environmental impact and admin costs. It is your responsibility to make sure that we have your correct contact details and that you check your emails regularly.
Phone Number*
Format: 00000 000 000.
Address*

Street Address

Street Address Line 2 (optional)

CityCounty

Postcode
I give permission for Circomedia to send text messages relevant to my Youth Circus booking on the number provided aboveI do not give permission for Circomedia to send me text messages
I give permission for Circomedia to send occassional marketing text messages to the above numberI would not like to receive marketing messages via text
Your Child(rens) Details
How many of your children are attending Youth Circus for academic year 2025-2026?*
You will be shown fields for each child below, based on your answers
Child 1 Name*

Preferred PronounsFirst/Preferred NameLast Name
Child 1 Date of Birth*

DayMonthYear
Date of birth
Child 1 Youth Circus Group*
Classes are listed Mon-Sun.
Child 1 School (optional)
Child 2 Name*

Preferred PronounsFirst/Preferred NameLast Name
Child 2 Date of Birth*

DayMonthYear
Date of birth
Child 2 Youth Circus Group*
Classes are listed Mon-Sun.
Child 2 School (optional)
Child 3 Name*

Preferred PronounsFirst NameLast Name
Child 3 Date of Birth*

DayMonthYear
Date of birth
Child 3 Youth Circus Group*
Classes are listed Mon-Sun.
Child 3 School (optional)
We will list the named parent/carer on this form as the Primary Emergency Contact. Please provide a Secondary Emergency Contact below:
Secondary Emergency Contact (must be different to named parent/ carer)*

First NameLast Name
Relationship to child(ren)*
Emergency Contact Phone Number*
Format: 00000 000 000.
Photography Permissions

Occasionally Circomedia may take photos and/or videos of sessions, showcases or special events for marketing and other purposes. Please let us know if you'd like your child to be included, and how you'd like us to use images and footages.
All online & printed publicity, including social mediaOnly photos & videos that will be shared securely with parents (no public sharing)I do not wish for my child to be photographed or filmed for any reason
Are you sure?

If you select this option, you won't have the chance to download professional photos or videos of your child's Youth Circus classes & performances (normally taken during our annual May showcases). You can opt in to just this opportunity so that you don't miss out - photos are only shared with Youth Circus parents via secure online galleries:
I would like professional photos & videos of my child(ren)I would not like my child to be photographed for this opportunity
The above consents will apply throughout the world and for an indefinite period unless we are informed otherwise. We will never identify your child by name.
Health & Safety

You will need to fill out a separate health & safety form for each child attending. Please ensure you are filling in the correct information for each child (their names are automatically filled in at the top of the section to help you with this.
Child 1: {child1}
Does your child have any medical conditions, injuries (current or historic), illnesses, allergies, or other needs that we should know about? Please include anything you feel is relevant even if it seems small.*
Does your child need to bring any medication or other medical equipment to class? If so, please list this below and make sure that anything your child brings is clearly labelled in a bag.
Is there anything you would like us to be aware of such as a behavioural support need or additional requirement, and/or anything we can do to improve your child's experience? (e.g. anxiety, ASD, ADHD, carer support, visual or hearing impairment, benefits from extra encouragement, may need quiet time etc.)
Child 2: {child2}
Does your child have any medical conditions, injuries (current or historic), illnesses, allergies, or other needs that we should know about? Please include anything you feel is relevant even if it seems small.*
Does your child need to bring any medication or other medical equipment to class? If so, please list this below and make sure that anything your child brings is clearly labelled in a bag.
Is there anything you would like us to be aware of such as a behavioural support need or additional requirement, and/or anything we can do to improve your child's experience? (e.g. anxiety, ASD, ADHD, carer support, visual or hearing impairment, benefits from extra encouragement, may need quiet time etc.)
Child 3: {child3}
Does your child have any medical conditions, injuries (current or historic), illnesses, allergies, or other needs that we should know about? Please include anything you feel is relevant even if it seems small.*
Does your child need to bring any medication or other medical equipment to class? If so, please list this below and make sure that anything your child brings is clearly labelled in a bag.
Is there anything you would like us to be aware of such as a behavioural support need or additional requirement, and/or anything we can do to improve your child's experience? (e.g. anxiety, ASD, ADHD, carer support, visual or hearing impairment, benefits from extra encouragement, may need quiet time etc.)
We are committed to providing individual support for all our participants, in order to facilitate a creative, inclusive and safe environment.Information given is strictly confidential and will be used only to ensure your needs are met.
Youth Circus Collection

As part of our commitment to safeguarding, parents/carers are required to provide a list of people who are authorised to collect their children from Youth Circus sessions.

Please provide details of people who will be collecting your child(ren) from Youth Circus classes, including yourself. *

Rows	Full Name	Contact Telephone Number
Main Person
Authorised Person 2
Authorised Person 3
Authorised Person 4
Authorised Person 5
Authorised Person 6

Please do not be offended if you are asked for identification.
Please let us know of any changes to this list via email and with sufficient notice.
Anyone not on this form will be challenged and you/your emergency contact will be called.
Leaving Circomedia Unaccompanied

The safety of our students is our highest priority, including when leaving site at the end of class. However, we also understand that many children are mature enough to leave site without adult collection.

Parents/Carers may give permission for students to leave the Circomedia site unaccompanied at the end of sessions. Please note, if you select this option for your child to leave site unsupervised, you acknowledge that Circomedia's duty of care has finished, and your child is leaving as an unaccompanied minor.
I give permission for my child to leave the Youth Circus studio alone.I do not give permission for my child to leave the Youth Circus studio alone.Other
Rebooking & Cancellation Policy

Please familiarise yourself with our rebooking & cancellation policies.
Rebooking
- Direct Debit bookers: we automatically rebook your child each term
  (only availble in September and January)
- Termly Bookers: rebook by end of current term to secure space for the following term
Cancellations
- You can cancel at a half term break or end of term, but not mid-term
- You must email us at least two weeks before the next break to cancel
For more information, check out full rebooking & cancellation information on our website here.
Via monthly Direct Debit payments (only available in September and December)Via the website in termly paymentsI receive a bursary
Full Price - I (or the payee) am not currently in receipt of Jobseekers' Allowance, Income Support, or Housing BenefitConcession Rate - I (or the payee) am currently in receipt of Jobseekers' Allowance, Income Support, or Housing Benefit
Name of payee (this will be the name you use on our payment system, GoCardless - it may be your name or a partner/family member)*

First NameLast Name
Standard cost of the class onlyRound-up Level 1: standard cost plus £1.30 donation per monthRound-up Level 2: standard cost plus £3.30 donation per monthRound-up Level 3: standard cost plus £6.30 donation per monthStandard cost, plus a bespoke amount (email us to give details)
Standard cost of the class onlyRound-up Level 1: standard cost plus £1.30 donation per monthRound-up Level 2: standard cost plus £3.30 donation per monthRound-up Level 3: standard cost plus £6.30 donation per monthStandard cost, plus a bespoke amount (email us to give details)
Standard cost of the class onlyRound-up Level 1: standard cost plus £1.30 donation per monthRound-up Level 2: standard cost plus £3.30 donation per monthRound-up Level 3: standard cost plus £6.30 donation per monthStandard cost, plus a bespoke amount (email us to give details)
I am a UK taxpayer and I want to Gift Aid any donations I make in the future or have made in the past 4 years to Circomedia, Registered Charity Number 1056852I am not a UK Taxpayer and cannot Gift Aid my declarationsI am not donating to Circomedia
As a UK taxpayer, if you pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all your donations in that tax year it is your responsibility to pay any difference.
I give permission for Circomedia to set up my subscription for 2025 - 2026 as specified in the Direct Debit letter and understand the number of payments and what I will be charged for my child(ren)'s class(es).I confirm that I will not cancel my Direct Debit myself, but will contact Circomedia with relevant notice if my child no longer wishes to attend.I understand that Circomedia will automatically rebook my child for each new term of Youth Circus, unless informed otherwise.I understand that I can only cancel my child's place at the end of a (half) term with two weeks' notice.I understand that if I cancel with less than two weeks' notice, I may be required to pay until the end of term.
I understand that I must rebook for each term by the end of the current term, and that I may lose my child's place if I do not rebook on time.I understand that I can only cancel my child's place at the end of a (half) term with two weeks' notice.I understand that if I cancel with less than two weeks' notice, I may be required to pay until the end of term.
I understand that my child should attend as many classes as possible, and I agree to inform Circomedia via email when they cannot attend.I understand that failure to attend may result in my child's bursary place being cancelled.
Equal Opportunities Monitoring
Circomedia wants to meet the aims and commitments set out in its equality policy and build an accurate picture of Circomedia Youth Circus.

We need your help and co-operation to enable us to do this, but filling in this form is voluntary.

All information provided is confidential and is stored separately to your information above.
Please answer on behalf of your child(ren).
Child 1 Gender
If you prefer, please write your own term here
Child 1 Ethnicity
If you selected 'other', please type your answer below:
Child 2 Gender
If you prefer, please write your own term here
Child 2 Ethnicity
If you selected 'other', please type your answer below:
Child 3 Gender
If you prefer, please write your own term here
Child 3 Ethnicity
If you selected 'other', please type your answer below:
Should be Empty:

Youth Circus Regular Class Enrolment Form 2025 - 2026

Your Details

Your Child(rens) Details

Photography Permissions

Health & Safety

Youth Circus Collection

Rebooking & Cancellation Policy

Equal Opportunities Monitoring