Early Bird Form

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.*
Child's Full Name*
Child's Date of Birth*
DD slash MM slash YYYY
Child's Gender
Child's School (or Nursery)
Are there any medical issues or additional information that Breakout should be aware of?
Class
Deposit
Price:
Deposit
Price:
Deposit
Price:
Second Child's Details
Child's Full Name*
Child's Date of Birth*
DD slash MM slash YYYY
Child's Gender
Child's School (or Nursery)
Are there any medical issues or additional information that Breakout should be aware of?
Class
Deposit
Price:
Deposit
Price:
Deposit
Price:
Third Child's Details
Child's Full Name*
Child's Date of Birth*
DD slash MM slash YYYY
Child's Gender
Child's School (or Nursery)
Are there any medical issues or additional information that Breakout should be aware of?
Class*
Deposit
Price:
Deposit
Price:
Deposit
Price:
Fourth Child's Details
Child's Full Name*
Child's Date of Birth*
DD slash MM slash YYYY
Child's Gender
Child's School (or Nursery)
Are there any medical issues or additional information that Breakout should be aware of?
Class*
Deposit
Price:
Deposit
Price:
Deposit
Price:
Would you like to purchase a Breakout t-shirt for £12.00 (p+p included)?
Price: £ 12.00
T-shirt sizes are: ages 3-4, 5-6, 7-8, 9-11, 12-13, 14-15, S Adult, M Adult, L Adult, XL Adult. Please state what t-shirt size you would like in the 'additional information' box above. Your child's t-shirt will be posted to the address on this booking form. Delivery is for Zoom classes only. If classes are in-person, collection is on arrival on your child's first day at Breakout.
Total
£ 0.00
Terms & Conditions*
- I can confirm that I have read and understood the Terms and Conditions and Privacy Policy.
Please click the button below to process the payment

Breakout Performing Arts

Second Child's Details

Third Child's Details

Fourth Child's Details

Total