ENROLMENT – Impact Dance Factory

If you have any questions please email enquiriesimpactdancefactory@gmail.com

Student Name *

First

Last

Date of Birth *

Parent/Guardian Name *

First

Last

Student/Parent/Guardian Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Phone/Mobile *

Student/Parent/Guardian Email *

Email

Confirm Email

*Upon submission of this form, your payment receipt will be sent to this email address.*

Medical Conditions (N/A if Not Applicable) *

Current Medications (N/A if Not Applicable) *

Allergies (N/A if Not Applicable) *

Allergy Medication (N/A if Not Applicable) *

Emergency Contact *

First

Last

Emergency Contact Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Emergency Contact Phone/Mobile *

CLASSES

TROUPES/COMPETITION STUDENTS

COMPULSORY ENROLMENT FEE

Price: $51.18

*Includes Credit Card Processing Fee of $1.18

Total

$0.00

*Please note enrolment fee is non-refundable*

Credit Card Payment *

Card

Name on Card

ALL STUDENTS DANCE AT THEIR OWN RISK *