Student Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Mobile Phone *

Country

(###)

###

####

Second Mobile Phone

Eg: Second Parent

Country

(###)

###

####

Hawthorn Community and Youth Club. Parent/Guardian Consent if member is under 18years *

“I, the undersigned, approve of my son/daughter’s involvement in the activities of the Club. I accept full responsibility for my son/daughter and his/her belongings whilst taking part in such activity. I authorise the Officials of the Club, in the event of accident or illness, to obtain all necessary medical assistance and treatment, including blood transfusions and anesthetic and I agree to pay all such fees and expenses incurred. I also agree that the Officials/Leaders should be free of any responsibility for any accident or illness incurred during my son/daughter’s involvement in activities at the various centres and venues or whilst training or playing competitive sport.”

I Agree

Hawthorn Community and Youth Club. If member is over 18years

“I, the undersigned hereby apply for membership of the Hawthorn Community and Youth Club Incorporated, and agree to be bound by the Rules of the Club for the time being in force. I accept full responsibility for my involvement in my chosen activity and for my belongings whilst taking part in such activity. I authorise the Officials of the Club, in the event of accident or illness, to obtain all necessary medical assistance and treatment, including blood transfusions and anaesthetic and I agree to pay all such fees and expenses incurred. I also agree that the Officials/Leaders should be free of any responsibility for any accident or illness incurred during my involvement in activities at the various centres and venues or whilst training or playing competitive sport.”

I Agree

Kiki DC Policies and Procedures *

I have read Kiki Dance Collectives 'Policies and Procedures' located on the website. I agree to comply with these policies.

I Agree

Kiki DC Photo and Video Waiver *

I give full permission for my child to be photographed and videoed throughout the year and during performances for distribution to myself and other parents of the school. I understand that these photographs may be displayed at performances and DVD’s will also be produced. Photography and videos may also be used in Kiki Dance Collective emails, social media and on our website. I will let the principal know in writing if I would prefer my child not to be used in promotional material.

I Agree