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Enrolment Form
Please complete form after payment
Child’s Surname
First Name
Date of Birth
Gender
Male
Female
Classes (Please Tick Selection)
2-3 Year Old
Crawler
Toddler
3-5 Year Old
Infant Massage
Parents/Caregivers Name
Email
Address
Suburb
Post Code
Home Phone
Work
Mobile
Select the Day
Choose an option
Wednesday
Emergency Contact (other than above)
Name
Relationship to child
Phone Number
Mobile
Information
Medical Conditions or Allergies
Additional Needs or Disabilities
Do you give permission for digital media (e.g. photographs) of your child to be used for promotional material or media publications for The Mini Movement – Cairns? Y / N
Yes
No
How did you hear about us?
Disclaimer
I am aware that it is my responsibility to supervise and care for my child whilst in all Mini Movement classes. Whilst the facilitator takes care to consider all safety concerns, I am responsible for ensuring my own and my child’s wellbeing.
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