Booking Form - Breakout Performing Arts

Full Name of Parent*

Emergency Contact Number*

How did you hear about Breakout?*

Email*

Home Address*

Address Line 1 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*

Child's Gender*

Child's School (or Nursery)*

Are there any medical issues or additional information that Breakout should be aware of?*

Class (Please do not select a class that is fully booked.)*

Deposit

Price:

Deposit

Price:

Deposit

Price:

Second Child's Details

Child's Full Name*

Child's Date of Birth*

Child's Gender*

Child's School (or Nursery)*

Are there any medical issues or additional information that Breakout should be aware of?*

Class (Please do not select a class that is fully booked.)*

Deposit

Price:

Deposit

Price:

Deposit

Price:

Third Child's Details

Child's Full Name*

Child's Date of Birth*

Child's Gender*

Child's School (or Nursery)*

Are there any medical issues or additional information that Breakout should be aware of?*

Class (Please do not select a class that is fully booked.)*

Deposit

Price:

Deposit

Price:

Deposit

Price:

Fourth Child's Details

Child's Full Name*

Child's Date of Birth*

Child's Gender*

Child's School (or Nursery)*

Are there any medical issues or additional information that Breakout should be aware of?*

Class (Please do not select a class that is fully booked.)*

Deposit

Price:

Deposit

Price:

Deposit

Price:

Would you like to purchase a Breakout t-shirt for £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. Collection is on arrival on your child's first day at Breakout. If signing up for the Summer Holiday Workshop your child gets a FREE t-shirt included with the workshop fee - please don't purchase one here unless you would like an extra t-shirt.

Price: £ 12.00

Total

£ 0.00

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