Half Term Form – The Painty Place

Child Details

Name of Child: *

Gender *

Date Of Birth *

Street Address *

Apartment, suite, etc

State/Province

ZIP / Postal Code

Parent/Guardian Details

Name of Parent/Gardian *

Phone *

Email Address *

Alternative Contact Name *

Alternative Contact Number *

Medical Details

Doctor's Name *

Surgery Name *

Doctor/Surgery Contact Number *

Please state any medical history/allergies we need to be aware of:

Please Tick and sign: *In order to maintain a safe and happy learning environment I understand that my child must behave appropriately at all times.

I am happy for photographs or video to be taken during the course for parents to receive by mail.I am happy for photographs or video to be taken and used for future publicity for Dance Your Art Out, Monnow Ballet, Painty Place and/or our websites (paintyplace.com and monnowballet.co.uk).