Part Payment -Term 1, 2019

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