Katz Acting School Student Enrolment Form

KATZ ACTING SCHOOL ENROLMENTFORM EMAIL:

1st STUDENT DETAILS / 2nd STUDENT DETAILS
First Name: / Click or tap here to enter text. / First Name: / Click or tap here to enter text. /
Family Name: / Click or tap here to enter text. / Family Name: / Click or tap here to enter text. /
Age: / Click or tap here to enter text. / Age: / Click or tap here to enter text. /
Preferred Name: / Click or tap here to enter text. / Preferred Name: / Click or tap here to enter text. /

AT THIS STAGE, A SIGNATURE IS NOT REQUIRED AT THE BOTTOM OF THIS FORM. THIS ENROLMENT FORM WILL BE PROVIDED AT THE FIRST CLASS TO BE SIGNED BY THE PROVIDED PARENT OR LEGAL GUARDIAN.

1st PARENT OR LEGAL GUARDIAN / 2nd PARENT OR LEGAL GUARDIAN
First Name: / Click or tap here to enter text. / First Name: / Click or tap here to enter text. /
Family Name: / Click or tap here to enter text. / Family Name: / Click or tap here to enter text. /
Relationship to Student: / Click or tap here to enter text. / Relationship to Student: / Click or tap here to enter text. /

MEDICAL INFORMATION

Please advise whether the student or students have a medical condition that KATZ Acting School needs to be aware (diabetes, asthma, allergies, a physical injury etc.)

Name of Student / Does student have a medical condition or special needs? / Can Student Self-Medicate? Please provide information. / Does the Student have Medical Care Plan? / Anything else KATZ should be aware of to ensure the student’s safety?
Click or tap here to enter text. / Choose an item. / Choose an item. / Choose an item. / Click or tap here to enter text.
Click or tap here to enter text. / Choose an item. / Choose an item. / Choose an item. / Click or tap here to enter text.

Please Note. KATZ employees cannot administer medication. If it is considered that medication is required and the student cannot self-medicate, one of the emergency contacts will be advised for further action. If the KATZ employee believes an ambulance is required, one will be called and an emergency contact will be advised as soon as practicable.

If you said “yes” for “Does the Student have a Medical Care Plan”. A copy should be provided to KATZ Acting School so it can be made available to a medical professional should it be necessary.

EMERGENCY CONTACTS
Name: / Click or tap here to enter text. / Name: / Click or tap here to enter text. /
Mobile: / Click or tap here to enter text. / Mobile: / Click or tap here to enter text. /
Home: / Click or tap here to enter text. / Home: / Click or tap here to enter text. /
Email: / Click or tap here to enter text. / Email: / Click or tap here to enter text. /

Please Note. No child will be allowed to leave a KATZ class unless picked up by one of the above primary carers or emergency contacts. KATZ Acting School will require written approval by a primary carer before the student will be released into the custody of any other person.

I, Click or tap here to enter text., Parent/Guardian of the child/children listed on this enrolment form, declare that to the best of my knowledge:

The information provided to KATZ Acting School is correct and complete.
I have provided all information regarding my child or children that ensures their safety, other students safety and KATZ personnel safety while participating in KATZ Acting School activities.

If any information provided on this form requires amending, I will provide such amended information in writing to KATZ Acting School.

I give KATZ Acting Schoolpermission to release photographic images/videos/other media of my child/children to promote the KATZ Acting Schoolin newspapers, magazines television and other forms ofmedia including KATZ Acting School website Only activitiesassociated withKATZ Acting School will be released. This consent will stay in place until KATZ Acting School receives, in a writing, withdrawal of this consent.

Ifyou do not wish to provide consent,please insert cross here (☐)

SIGNATURE of Parent or Legal Guardian: ______

PRINT NAME of Parent or Legal Guardian: ______

RELATIONSHIP to Student:______

DATE SIGNED:DD / M M / Y YYY

Please go to the web site to submit this form electronically:

Or email the form to

Information collected on this form is strictly for KATZ Acting School only.