Registration
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Cirkidz Inc is a registered charity with the Australian Charities And Not-For-Profits Commission. Donations are Tax Deductible. The Cirkidz Community thank you for you donation that will help us to do such things as upgrade our equipment and provide more services to the community. The kids, trainers and staff thank you for your thoughtful contribution to the sustainability of youth arts in South Australia. Please keep your invoice or receipt to claim your Tax Deduction.
Event:
Start Date/Time:
End Date/Time:
Fee per Family:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
*
Account Contact
Agency Contact
Father
Grandparent
Guardian
Mother
Other
Parent
Student
Home Phone:
*
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State/Prov:
*
Postal Code:
*
Emergency Contact Info
*
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
They/Them
Undisclosed
Birth Date:
*
(format=dd/mm/yyyy)
Permission to take photos? Y/N:
Artist Development Program?:
Have a Promotional Code?:
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
They/Them
Undisclosed
Birth Date:
*
(format=dd/mm/yyyy)
Permission to take photos? Y/N:
Artist Development Program?:
Have a Promotional Code?:
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
They/Them
Undisclosed
Birth Date:
*
(format=dd/mm/yyyy)
Permission to take photos? Y/N:
Artist Development Program?:
Have a Promotional Code?:
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
They/Them
Undisclosed
Birth Date:
*
(format=dd/mm/yyyy)
Permission to take photos? Y/N:
Artist Development Program?:
Have a Promotional Code?:
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
They/Them
Undisclosed
Birth Date:
*
(format=dd/mm/yyyy)
Permission to take photos? Y/N:
Artist Development Program?:
Have a Promotional Code?:
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number:
*
Visa
Mastercard
Name as it appears on card:
*
Nickname:
Card Expiration Month:
*
01
02
03
04
05
06
07
08
09
10
11
12
Exp Year:
*
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
Address Line 1:
Address Line 2:
City:
State/Prov:
Postal Code:
*
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