Enrolment details Please fill enrolment form and send to Alex Ewens at Breathe Dance Studio via Email:

breathedancestudio@hotmail.com or Post: 96 Crisp Cct Bruce ACT 2617 Signatures can be completed amongst arrival of first class.

Payment details: Payments: Please pay via a Bank transfer to secure your place in desired classes. Bank details: Account Name: Alexandra Shea Ewens Bsb: 06 2907 Account No: 100 492 45 Please unsure you have written your name in the description box within the transfer please. Cash option: To pay cash upon arrival of first class. Please understand this does not secure your spot within the classes if already filled by dancers that have paid via Bank transfer.

Note: Receipts will be handed out upon arrival of first class.

First Name Last Name D.O.B Address Suburb State Postcode Mobile Home Ph. Email Emergency Contact Contact No. Class/ Classes attending

Payment (please select) 1 class ($150) 2 classes ($275) 3 classes ($400) All classes ($600) Payment type Bank transfer Cash (paid at first class)

(Eg. Yes Membership)

(Eg. Yes paid 17/01/13 transfer name A.Ewens)

Disclaimer
Instruction I understand that the instructions given throughout the class are only intended as guidance for the student. It is my responsibility to adjust my movement according to my limitations to ensure no personal injury occurs. I hereby declare that i take full responsibility whilst under instruction from Breathe Dance Studio.

Class availability I understand that students who register and pall in full for a term pass (prior to the start of term) will be given preference if classes are full. I also understand that registration alone does not secure my place in class.

Payment I understand that all classes must be paid in full within the first 3 weeks of term or casual rates will be charged. I understand that the term pass allows me 10 classes in a term. If I am unable to attend all 10 classes within that term, it is my responsibility to make up the missed class within the same term. I understand that Breathe Dance Studio offers a seven day cooling off period for cancellations. After this time all classes are non refundable for absence, non-attendance, change of mind or any other personal circumstances or reason.

Privacy I agree to provide details here to Breathe Dance Studio for their business and marketing activities. I understand these details will not be provided to any third party without my consent.

Signature

Date