Breakout Performing Arts
07905 831 508
info@breakoutschool.co.uk
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Booking Form – Early Bird
Full Name of Parent
*
Emergency Contact Number
*
How did you hear about Breakout?
*
Email
*
Home Address
*
Street Address
Address Line 2
Town/City
County
Postal Code
Number of children attending. If more than one child is attending please list in order of age, starting with the oldest.
*
1
2
3
4
Child's Full Name
*
Child's Date of Birth
*
Child's Gender
Male
Female
Child's School (or Nursery)
Are there any medical issues or additional information that Breakout should be aware of?
Class
Please Select a Class
3-5 Yrs Performing Arts, Wednesday - 4:30pm
3-5 Yrs Performing Arts, Saturday - 9am
3-5 Yrs Performing Arts, Saturday - 10:45am
6-16 Yrs Performing Arts, Wednesday - 4:30pm
6-16 Yrs Performing Arts, Saturday - 9am
Summer Holiday Workshop
Deposit
Price:
£ 18.00
Deposit
Price:
£ 30.00
Deposit
Price:
£ 30.00
Second Child's Details
Child's Full Name
*
Child's Date of Birth
*
Child's Gender
Male
Female
Child's School (or Nursery)
Are there any medical issues or additional information that Breakout should be aware of?
Class
Please Select a Class
3-5 Yrs Performing Arts, Wednesday - 4:30pm
3-5 Yrs Performing Arts, Saturday - 9am
3-5 Yrs Performing Arts, Saturday - 10:45am
6-16 Yrs Performing Arts, Wednesday - 4:30pm
6-16 Yrs Performing Arts, Saturday - 9am
Summer Holiday Workshop
Deposit
Price:
£ 18.00
Deposit
Price:
£ 30.00
Deposit
Price:
£ 30.00
Third Child's Details
Child's Full Name
*
Child's Date of Birth
*
Child's Gender
Male
Female
Child's School (or Nursery)
Are there any medical issues or additional information that Breakout should be aware of?
Class
*
Please Select a Class
3-5 Yrs Performing Arts, Wednesday - 4:30pm
3-5 Yrs Performing Arts, Saturday - 9am
3-5 Yrs Performing Arts, Saturday - 10:45am
6-16 Yrs Performing Arts, Wednesday - 4:30pm
6-16 Yrs Performing Arts, Saturday - 9am
Summer Holiday Workshop
Deposit
Price:
£ 18.00
Deposit
Price:
£ 30.00
Deposit
Price:
£ 30.00
Fourth Child's Details
Child's Full Name
*
Child's Date of Birth
*
Child's Gender
Male
Female
Child's School (or Nursery)
Are there any medical issues or additional information that Breakout should be aware of?
Class
*
Please Select a Class
3-5 Yrs Performing Arts, Wednesday - 4:30pm
3-5 Yrs Performing Arts, Saturday - 9am
3-5 Yrs Performing Arts, Saturday - 10:45am
6-16 Yrs Performing Arts, Wednesday - 4:30pm
6-16 Yrs Performing Arts, Saturday - 9am
Summer Holiday Workshop
Deposit
Price:
£ 18.00
Deposit
Price:
£ 30.00
Deposit
Price:
£ 30.00
Breakout T-shirt
Price:
£ 10.50
Quantity:
Would you like to purchase a Breakout t-shirt for £10.50 to collect on arrival?
Total
£ 0.00
Terms & Conditions
*
I can confirm that I have read and understood the
Terms and Conditions
and
Privacy Policy
.
Credit Card (this card must be registered to the address above)
American Express
Discover
MasterCard
Visa
Card Number
Expiration Date
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
Security Code
Name on Card (exactly as it appears, e.g. Mr T Smith)
