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 Part-time Drama and Performance School commencing Summer Term 2010:

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

Juniors 2 (7 - 8 years): Wednesdays 5pm - 6pm (St James's Church, Hampton Hill)

Intermediates (9 - 12 years): Tuesdays 4.30pm - 5.45pm (St Francis de Sales, Hampton Hill)

Seniors/Advanced (12 - 17 years): Tuesdays 5.45 - 7pm (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.