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Flipside Circus
117 Mina Parade
Alderley QLD 4051
Ph (07) 3352 7233
Fax (07) 3856 6411




First Name:
Surname:
Gender:	MaleFemale
Date of Birth
Date:
Month:
Year:
What school does your child attend?:

First Name:
Surname:
Street Address:
Suburb:
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Home Phone Number:
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Are parent/guardian 2's details the same as parent/guaridan 1?:	YesNo
If you answered "no", the Parent/guardian 2 section is not compolsury to fill out. Please proceed to the "More Information" section.

First Name:
Surname:
Street Address:
Suburb:
Postcode:
Home Phone Number:
Mobile 2 (no spaces):
Email Address:
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At what address does the participant live?:
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How did you hear about Flipside Circus?:
Has your child participated in a Flipside Circus School Holiday Workshop before?:	YesNo

Does your child have any impairments or disabilities?:	YesNo
If yes, what form (eg. physical, visual, intellectual)?:
Are there any relevant limitations or medical conditions?:	YesNo
If yes, please give further information::
Is your child on any medication?:	YesNo
If yes, please give further information::
Does your child suffer from any allergies of any kind?:	YesNo
If yes, please give further information.:
Do you have private health insurance?:	YesNo
If yes, who is your insurance company?:

JULY SCHOOL HOLIDAYS 2013
Kindy School Holiday Workshops:
15 Tricks in 1 Day Workshop (6 to 16 years):
3 Day Performance Workshop (6 to 16 years) $140:
5 Day Circ-cation Workshop (7 to 16 years) $590 per child:

OCTOBER SCHOOL HOLIDAYS 2013
Kindy School Holiday Workshops $25 per child:
15 Tricks in 1 Day Workshop (6 to 16 years):
3 Day Performance Workshop (6 to 16 years) $140:
5 Day Circ-cation Workshop (7 to 16 years) $590:

DECEMBER 2013/JANUARY 2014 SCHOOL HOLIDAY WORKSHOPS
Kindy School Holiday Workshops $25 per child:
15 Tricks in 1 Day Workshop (6 to 16 years):
3 Day Performance Workshop (6 to 16 years) $140:
5 Day Circ-cation Workshop (7 to 16 years) $590:

As the parent or legal guardian/caregiver of the above listed student I hereby consent to the above named person participating in the programs offered by Flipside Circus. I recognise that potentially severe injuries, including sprains, strains, broken bones, permanent paralysis or death, can occur in any activity involving height or motion or juggling. I also realize that my child will be performing and training for circus events using various training devices. I further understand that while the payment of tuition and registration fees constitutes a part of the consideration due to Flipside Circus for allowing my child to use the facilities and equipment of Flipside Circus, an additional and important part of the consideration due to Flipside Circus is this signed release form. Therefore, in consideration for allowing my child to use the Flipside Circus’s equipment and facilities, I hereby forever release Flipside Circus its management committee, officers, employees, trainers, and coaches from all liability for any and all damage and injuries suffered by my child while under the instruction, supervision or control of Flipside Circus, its management committee, officers, employees, teachers or coaches. As the parent or legal guardian of the aforementioned person, I hereby agree to individually protect for the possible future medical expenses which may be incurred by my child as a result of any injury sustained while training or performing at, for, or under the direction of Flipside Circus.
I have understood and accept these risks
I have communicated these risks to my child

All Flipsipe Circus participants must adhere to the Statement of Ethics and Code of Conduct.
I have read, discussed with my child and agree to the above terms

It may be essential at some time for the lead trainer or Circus staff accompanying your son/daughter to have the necessary authority to obtain any urgent medical treatment which may be required whilst at performance or training. Being the parent/guardian of the above named child, I hereby give permission for the Flipside staff to give the immediately necessary authority on my behalf for any medical or surgical treatment recommended by competent medical authorities, where it would be contrary to my son/daughter's interest, in the doctor's medical opinion, for any delay to be incurred by seeking my personal consent. This acknowledgment of risk, waiver of liability and emergency medical consent form, having been read thoroughly and understood completely, is signed voluntarily as to its content and intent.
I agree to the emergency medical consent as detailed above

Sometimes during workshops photographs and/or video footage may be taken. These items may be used either within Flipside Circus, on television, on the Flipside Circus web site or in printed material. The photos will be used as promotion and will NOT contain your child’s name. Do you give permission for us to take photographs and/or video footage?
Yes, I consent No, I do not consent

Would you like to be kept informed of all the latest Flipside news, new classes, holiday workshops and show invites? If yes, please sign up for our email newsletter. We guarantee that we will not pass your email address onto any third party.
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I have read, understood and agree to all of the above information