* Surname            

                                * Child's Name   

                                Date of Birth       

                                Mothers Name   

                                Fathers Name    

                                Address             

                                Home Phone              

                                Mobile (Mum)            Mobile (Dad)   

                                Email Address       

                                Emergency contact   

                                Medical conditions e.g. Asthma etc.   

                                Genre/s in which to be enrolled:        Ballet                              Contemporary          

                                                                                            Jazz                                  National/Character 

                                                                                            Tap                                   Hip Hop                  

                                Comments       

* I give permission for Pegasus Academy of Dance to use photographs of myself or my child for promotional media.            Please Select No Yes

* I have read the terms and conditions as stated in the 'Fees Schedule' page.    Please Select No Yes