TO BE COMPLETED BY PARENTS/GUARDIANS - ONE FORM PER CHILD PLEASE

NAME OF PARENT/GUARDIAN................................................................................................

ADDRESS: .........................................................................................................................

.........................................................................................................................................

TEL. NO: ...........................................................................................................................

EMAIL: ..............................................................................................................................

NAME OF CHILD:..................................................................................................................

DATE OF BIRTH:..................................................................................................................

INTERESTS/HOBBIES:..........................................................................................................

HEALTH PROBLEMS (if any):..................................................................................................

I found out about the course from:........................................................................................

I would like to reserve a place on the following actfirst Drama Group commencing Spring Term 2012:

Juniors 1 (5 - 7 years): Wednesdays 4pm - 5pm (St James's Church, Hampton Hill)

Juniors 2 (8 - 10 years): Wednesdays 5pm - 6pm (St James's Church, Hampton Hill)

Intermediates 1 (9 - 11 years): Tuesdays 4pm - 5.10pm (St Francis de Sales, Hampton Hill)

Intermediates 2 (11 - 13 years): Tuesdays 5.15pm - 6.30pm (St Francis de Sales, Hampton Hill

Seniors (13 - 17 years): Tuesdays 6.30pm - 7.45pm (St Francis de Sales, Hampton Hill)

Please circle clearly which class you are interested in.

I enclose a cheque for £15.00, made payable to J.K. KIRKE.*
I have read and accept the 'conditions of inclusion on the course'.

SIGNED: ...................................

DATE:.......................................

Please print, complete & return this form together with your payment to:

J.K.Kirke
actfirst
12 Bye Ways,
Twickenham
Middx TW2 5JN

*In the unlikely event of a cancellation you will be refunded in full.