Name of Member: *

(ONE FORM PER MEMBER)

First Name

Last Name

Date of Birth *

MM

DD

YYYY

What age group applies to this Member? *

Little Stars

Juniors

Seniors

Ladies

Name of person completing this form *

*Parents/Careers

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact number *

Country

(###)

###

####

First Aid *

I give permission for First Aid to be administered to myself or child.

Yes

No

Photography *

I give permission for images and footage of myself or my child to be used by Mascot Physie for publicity. Any photographs or video footage captured may be used on our website, Facebook page, or for marketing materials.

Yes

No

Studio Rules / Club & BJP Code of Conduct *

I have read & understand all the rules and agree to abide by them. I acknowledge and accept that while Mascot Physical Culture Club takes the utmost care, physie may risk personal injury. I/my child agree to participate at my own risk.

I agree

I disagree

Payment for Club Insurance & Term 1 Class Fees (FOR 5 YEARS + ONLY) *

*Annual Club Insurance - $40 *Term 1 Class Fees - $100 ($10 per class x 10 weeks = $100) TOTAL PAYMENT = $140 Online Banking Details: COMMONWEALTH BANK ACCOUNT NAME: Mascot Physical Culture Club BSB: 062200 ACCOUNT NUMBER: 0090 4273

Bank Transfer = $140

Cash = $140

I'm in the Little Stars Preschooler's class

Payment for LITTLE STARS PRESCHOOLERS ONLY! *

*Term 1 Class Fees - $50 ($5 per class x 10 weeks = $50) TOTAL PAYMENT = $50 Online Banking Details: COMMONWEALTH BANK ACCOUNT NAME: Mascot Physical Culture Club BSB: 062200 ACCOUNT NUMBER: 0090 4273

Bank Transfer = $50

Cash = $50

Not in the Little Stars Preschooler's class