Cirkidz Online Registration

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* * * * * Welcome to CIRKIDZ CIRCUS SCHOOL and SCHOOL HOLIDAY PROGRAM * * * * * SA Circus Centre also offer programs for those interested in higher level training with our ARTIST DEVELOPMENT PROGRAM. Please tick the box "Artistic Development Program" and the Artistic Development Coordinator will be in touch.

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Referral Information

How did you hear about us?*

Referral Name*

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Post Code*

Primary Phone*

Additional Info

Emergency Contact Info*

Permission to take photos? Y/N

Interested in Artist Program?*

Have a Promotional Code?

Contact #1

Parent or Guardian #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone *

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Parent or Guardian #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Special Needs (Leave blank if NONE)

Proof of Covid 19 Vaccination Passport (12yo - Adult) supplied.

Permission to take photos? Y/N

Artist Development Program?

Have a Promotional Code?

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Special Needs (Leave blank if NONE)

Proof of Covid 19 Vaccination Passport (12yo - Adult) supplied.

Permission to take photos? Y/N

Artist Development Program?

Have a Promotional Code?

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Special Needs (Leave blank if NONE)

Proof of Covid 19 Vaccination Passport (12yo - Adult) supplied.

Permission to take photos? Y/N

Artist Development Program?

Have a Promotional Code?

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Special Needs (Leave blank if NONE)

Proof of Covid 19 Vaccination Passport (12yo - Adult) supplied.

Permission to take photos? Y/N

Artist Development Program?

Have a Promotional Code?

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Special Needs (Leave blank if NONE)

Proof of Covid 19 Vaccination Passport (12yo - Adult) supplied.

Permission to take photos? Y/N

Artist Development Program?

Have a Promotional Code?

Enroll in Classes

Select Class *

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Post Code*

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Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

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Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

Additional Info

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