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 Saturday 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. submit
