Home|Viva Circus Kids – Register

Register for Term 2, 2021

Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Parent/Guardian Name*
First Last
Parent/Guardian Email*
Parent/Guardian Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent/Guardian Contact Number 1*
Parent/Guardian Contact Number 2
Does your child have any medical conditions / allergies or is there anything else that you would like to ask or tell us about?*
Please tell us about tell us about your child’s acrobatics or circus experience.*
Photo Consent*
I agree to the media policy.
I consent for Viva Aerial Dance to use images / video footage of my child / me for the purpose Viva Circus Kids class publicity (all media, including internet).
I understand that this may include the place and date of the image for publication without compensation to my child / me.