Balmain Dance Academy

Child's Name *
Age *
Date of Birth (DD.MM.YYYY)*
Parents/Guardians Name(s)*

Home Address *
Suburb *
Postcode *
Home Phone *
Email Address *
Mobile Number

Please indicate which classes you are enrolling in:

Are there any medical conditions which should be known about?	Yes No
If yes, please list:
I give permission for my child to receive medical treatment, if necessary.	Yes No
I undertake to pay the term's fees within 14 days, or incur an extra accounting fee of $10.00 if not fully paid within 3 weeks of due date, and an additional fee of $10.00 if not fully paid by the end of term.


All cheques to be made payable to "Balmain Dance Academy" Direct Deposit Details available on request.