Select Your Class *

Option 1

Option 2

What days will you be attending?

For our free programs, we prefer students to attend the whole week if possible

Monday

Tuesday

Wednesday

Thursday

Friday

Student Name *

First Name

Last Name

Student's DOB *

MM

DD

YYYY

Student Name (second student)

First Name

Last Name

DOB (second student)

MM

DD

YYYY

Student Name (third student)

First Name

Last Name

SOB (third student)

MM

DD

YYYY

Student Name (fourth student)

First Name

Last Name

DOB (fourth student)

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

First Name

Last Name

Does any of the following apply to the student?

Please select all that apply for all students that you are enrolling.

Illness or other condition that may affect ability to partake in circus activities

Regular medication

Allergies

Emotional or behavioural challenges

Other relevant information

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 agree to receive future marketing and promotional emails from Circus Kumarani

Yes