ENROLMENT & CREDIT APPLICATION

AMJAZZ Dance Studios is a family-owned business, running classes in Rotorua since 1996.

Dancer's Full Name

Date of Birth

Mother's or Caregiver's Name

Are you the billpayer?

Yes No

Father's or Caregiver's Name

Are you the billpayer?

Yes No

Postal Address

Suburb

Postcode

Home

Mobile

Work

Physical Address (if different from above)

Doctor's Name

Medical Centre

Phone Number

Please list any Medical Conditions or Learning Disabilities which might help our teachers to support your dancer:

Details of person paying account (if different from above):

Name

Relationship

Postal Address

Postcode

Home

Work

Mobile

Please confirm the email you would like your AMJAZZ newsletters and accounts sent to:

Email Address(es)

Occasionally AMJAZZ Ltd may record your child’s image via video or still camera. This agreement allows AMJAZZ Ltd to use those images for marketing, promotional or training purposes. Do you agree to allow this?

Yes No

I agree, as the form completer and bill payer, I am over 18 years of age and are prepared to pay all dance fees and associated costs in FULL 4 weeks prior to the end of each term. I have read and agree with the terms and conditions detailed in the AMJAZZ Fee Payment Policy and Family Policy.

Name

Date