Enrollment Form
Gippsland Messy Play Term 4
Child's Information
Child's Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Female
Male
Attendance Information
Session
*
Is there a sibling
*
Yes
No
Sibling Name
First Name
Last Name
Sibling Name
First Name
Last Name
Additional Information regarding Attendance
Child dietary or diagnosis Information
Additional information for additional adjustments etc dietary/ASD/Sensitivity etc
Patents/Guardian & Emergency Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Relationship
*
Mother, Father, etc
Mobile Phone Number
*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Address
*
Same with the child
Different Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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My Products
*
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Casual Class Pass
Cost per session/per person
$
20.00
AUD
Quantity
1
2
3
4
5
Item subtotal:
$
0.00
AUD
Casual Class Pass - Sibling
Cost per session/per person
$
20.00
AUD
Quantity
1
2
3
4
5
Item subtotal:
$
0.00
AUD
10 session pass
$
180.00
AUD
Quantity
1
2
3
4
5
6
7
8
9
10
I consent to photo’s being taken during sessions, Yakini and Gippsland Messy Play will not be capturing faces or identifiable parts of your children/participants (aerial views only)
*
I consent
I do not consent
Signature
*
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Continue
Continue
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