Circus Holiday Programs: Children MUST be signed in and out each day. Please do not attend if there is any sign of sickness within your whānau *

I understand

Select Your Location/Dates *

WAITING LIST Paparoa Memorial Hall - Wednesday 24th Sept (10-2)

Dargaville Selwyn Park School- Thursday 25th Sept (10-2)

Student Name *

First Name

Last Name

DOB *

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DD

YYYY

Student Name (second student)

First Name

Last Name

DOB (second student)

MM

DD

YYYY

Student Name (third student)

First Name

Last Name

DOB (third student)

MM

DD

YYYY

Student Name (fourth student)

First Name

Last Name

DOB (fourth student)

MM

DD

YYYY

Parent/Guardian (students under 18yrs) *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Does the student have any conditions (medical/physical/behavioral) that might affect their ability to partake in circus activities? *

Yes

No

Does the student require any additional support needs? (eg. medication, sensory environment) *

Yes

No

Does the student have any allergies? *

Yes

No

My child/student is allowed to leave the program alone *

Yes

No

Student can be photographed/videoed while participating in these activities *

Yes

No

If yes to the above: I consent to these images/videos being used for publicity purposes (including social media promotions)

Yes

I have read and understand all our terms and conditions and financial and medical responsibilities. *

By clicking 'submit application' you are agreeing to all our terms and conditions, financial and medical conditions.

Yes

I would like to be added to the Kumarani newsletter list to hear about more circus opportunities

Yes please!

No thanks