Student Details:

First Name*
Surname*
Address*
Suburb*		Postcode*
Home Phone*		Mobile
Email

I give consent for me/my child/child in my care to be photographed by Westside Circus Inc employees for promotional or archival purposes*

Yes No

Emergency Contact:

First Name*
Surname*
Primary Number*
Secondary Number

Are there any cultural issues that Westside Circus should be aware of? If yes please specify, otherwise please enter NA*
Are there any custody, access or court arrangments which Westside Circus should be aware of? If yes please specify, otherwise please enter NA*

Class Information*:

I would/ my child would like to enroll in:

Fitzroy Classes
Child Age	Class Name

3-5	Tick Tock Team (Thursday) Zap Team (Friday) Splat Team (Saturday) Pop Team (Saturday)
5-7	Spin Bunch (Wednesday) Crunch Bunch (Friday) Balance Bunch (Saturday)
8-12	Zoom Troupe (Monday) Whoosh Troupe (Monday) Tangle Troupe (Tuesday) Swoop Troupe (Saturday)
11-12	Tumble Company (Saturday)
12-25	Westside Youth (Thursday)
18-80	Stunt Society (Monday)

Medical Information:

The information required below will be used solely by Westside Circus staff and medical personnel in the event of injury or medical crisis. Please note, Westside Circus does not keep asthma medication or EpiPen on its premises. It is the responsibility of the student, or parent, carer or guardian of the student if under the age of 18, to bring and administer any asthma or EpiPen medication.

 

Does the student suffer from asthma? If yes please specify, otherwise please enter NA*
Does the student suffer from any allergies? If yes please specify, otherwise please enter NA*
Does the student suffer from any other illness or condition that might affect his or her ability oto take part in Westside Circus activities? If yes please specify, otherwise please enter NA*
Is the student taking any regular medication? If yes please specify, otherwise please enter NA*
Does the student suffer from any emotional or behavioral problems that Westside Circus should be aware of? If yes please specify, otherwise please enter NA*
Do you give permission for Westside Circus staff to apply antiseptic, bandaids and cold packs for the treatment of minor injuries? If yes please specify, otherwise please enter NA*

Acknowledgement:

By accepting the acknowledgement at the end of this form, I accept that: Westside Circus Inc. will exercise reasonable care in the course of any Westside Circus activity. There is, nonetheless, an inherent risk of harm involved in any Westside Circus activity. Other participants at Westside Circus activities may participate in dangerous, reckless or negligent manner, or with lack of skill. The student may be injured in the course of participating in any Westside Circus activity. It may be necessary for Westside Circus to administer first aid to the Participant and to obtain medical advice and/or treatment on the Participants’ behalf and that I will be required to reimburse Westside Circus Inc. for any expenses incurred by it in this regard, including ambulance costs. Westside Circus Inc. retain the right and discretion to refuse the student permission to use his/her own equipment in the course of participating in a Westside Circus activity.
I have read and completed this from carefully and the information supplied by me is correct to the best of my knowledge.

By agreeing to this indemnity clause I, * (the above named participant/ the above named participants’ parent/guardian) AGREE TO INDEMNIFY Westside Circus Inc. for any loss or damage suffered by it and for any action, claim or proceeding brought against it, arising from the Participants participation in ay Westside Circus Activity, whether caused by negligence of the Participant, defects in the participants personal equipment, or any other fault on part of the Participant.

I agree* Yes No

Dated* (dd/mm/yyyy)

The information in this form is held in the strictest of confidence. It will only be released to you, your nominated parent, carer or guardian, to medical staff in the event of an injury or medical emergency or when required by law.