NAME: ______________________ F/M
D.O.B: __ __ / __ __ / __ __
ADDRESS: _______________________
________________________________
________________________________
________________________________
TEL NO.:_________________________
EMERGENCY CONTACT NO.: _______
________________________________
MEDICAL INFORMATION/ SPECIAL NEEDS:
Have you previously attended ROX? Yes/No
Days required Mon/Tue/Weds/Thu/Fri
I enclose payment of £_____ Payable to
“ROX School of Dance and Drama”.
Parent/Guardian Signature:
Date: __ __ / __ __ / __ __
Unit 3, Hove Business Centre,
Fonthill Road,
HOVE
BN3 6HA
Tel: 01273 208 513
www.roxschoolofdancing.co.uk
Email: sophierox@btconnect.com
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