Part Payment -Term 1, 2019

1
Your Name* This field is required.
First Name
Last Name
2
Child's Name* This field is required.
First Name
Last Name
3
Contact Email Address* This field is required.
example@example.com
4
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
5
Back-up Emergency Contact Phone Number (optional)
Area Code
Phone Number
6
Child's Age* This field is required.
7
Is there any personal or medical information we should know about your child?
8
What day would you like to book for?
Monday
Tuesday
Wednesday
Thursday
Saturday
9
From time-to-time we use children's images on our website and social media channels. Are you happy for your child's image to be used for this purpose?
YESNO
10
Choose a payment method
Credit Card
Online Banking
11
12
Should be Empty: